Provider Demographics
NPI:1760029961
Name:FULLER NEUROPSYCHOLOGY
Entity Type:Organization
Organization Name:FULLER NEUROPSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-239-2744
Mailing Address - Street 1:7032 SOUTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-3248
Mailing Address - Country:US
Mailing Address - Phone:817-239-2744
Mailing Address - Fax:
Practice Address - Street 1:2301 OHIO DR STE 130
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-3997
Practice Address - Country:US
Practice Address - Phone:817-239-2744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty