Provider Demographics
NPI:1184730756
Name:FULLER, AMY M (PHD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:FULLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:M
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:1380 PANTHEON WAY
Mailing Address - Street 2:#310
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232
Mailing Address - Country:US
Mailing Address - Phone:210-393-4650
Mailing Address - Fax:210-694-4600
Practice Address - Street 1:1380 PANTHEON WAY
Practice Address - Street 2:#310
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232
Practice Address - Country:US
Practice Address - Phone:210-393-4650
Practice Address - Fax:210-694-4600
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17295LPC101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
5169LCOtherBCBS
456168OtherVALUE OPTIONS