Provider Demographics
NPI:1841390333
Name:FULLER, LISA BETH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:BETH
Last Name:FULLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 NE 203RD ST
Mailing Address - Street 2:SUITE 214
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1900
Mailing Address - Country:US
Mailing Address - Phone:786-202-0474
Mailing Address - Fax:
Practice Address - Street 1:2627 NE 203RD ST
Practice Address - Street 2:SUITE 214
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33180-1900
Practice Address - Country:US
Practice Address - Phone:786-202-0474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6682103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical