Provider Demographics
NPI:1942258595
Name:FULLER, BRIAN JAY (PHD)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JAY
Last Name:FULLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5340 HOLIDAY TER
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-2196
Mailing Address - Country:US
Mailing Address - Phone:269-321-8564
Mailing Address - Fax:
Practice Address - Street 1:1662 E CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-4410
Practice Address - Country:US
Practice Address - Phone:269-321-8564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013172103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist