Provider Demographics
NPI:1750564829
Name:FULLER, JAMES WOODROW JR (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WOODROW
Last Name:FULLER
Suffix:JR
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 LARKWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294-4105
Mailing Address - Country:US
Mailing Address - Phone:804-967-0486
Mailing Address - Fax:
Practice Address - Street 1:8001 FRANKLIN FARMS DR RM 225
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-5117
Practice Address - Country:US
Practice Address - Phone:804-967-0486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-12
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040005741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAR65539Medicare UPIN
VA800003026Medicare PIN