Provider Demographics
NPI:1750379996
Name:FULLER, KIM (PHD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5665 PONCE DE LEON BLVD
Mailing Address - Street 2:ROOM 213
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2510
Mailing Address - Country:US
Mailing Address - Phone:305-284-6874
Mailing Address - Fax:305-284-1700
Practice Address - Street 1:5665 PONCE DE LEON BLVD
Practice Address - Street 2:ROOM 213
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2510
Practice Address - Country:US
Practice Address - Phone:305-284-6874
Practice Address - Fax:305-284-1700
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPY4602103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist