Provider Demographics
NPI:1801125489
Name:FULLER, CRAIG BENJAMIN
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:BENJAMIN
Last Name:FULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 E 90TH ST
Mailing Address - Street 2:APT. 2A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-5146
Mailing Address - Country:US
Mailing Address - Phone:917-300-8742
Mailing Address - Fax:
Practice Address - Street 1:210 W 70TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-4304
Practice Address - Country:US
Practice Address - Phone:917-300-8742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019953103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical