Provider Demographics
NPI:1770891616
Name:FULLER, HENRY III (MASTER OF SCIENCE OT)
Entity type:Individual
Prefix:MR
First Name:HENRY
Middle Name:
Last Name:FULLER
Suffix:III
Gender:M
Credentials:MASTER OF SCIENCE OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 GARTLEY ST
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ME
Mailing Address - Zip Code:04250-6431
Mailing Address - Country:US
Mailing Address - Phone:207-353-6806
Mailing Address - Fax:207-353-3038
Practice Address - Street 1:33 MILL ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ME
Practice Address - Zip Code:04250-6810
Practice Address - Country:US
Practice Address - Phone:207-353-4132
Practice Address - Fax:207-353-4815
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT246225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist