Provider Demographics
NPI:1982665675
Name:FULLER, DENNIS PAUL (PHD CCC SLP)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:PAUL
Last Name:FULLER
Suffix:
Gender:M
Credentials:PHD CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3691 RUTGER AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:314-977-4440
Mailing Address - Fax:
Practice Address - Street 1:3660 VISTA
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110
Practice Address - Country:US
Practice Address - Phone:314-977-5110
Practice Address - Fax:314-268-5111
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00071235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist