Provider Demographics
NPI:1275705337
Name:FULLERTON, LAURA 'GINNY' (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:'GINNY'
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 WEST LOOP S
Mailing Address - Street 2:STE 420
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-2900
Mailing Address - Country:US
Mailing Address - Phone:713-568-6837
Mailing Address - Fax:
Practice Address - Street 1:6300 WEST LOOP S
Practice Address - Street 2:STE 420
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-2900
Practice Address - Country:US
Practice Address - Phone:713-568-6837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33888103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical