Provider Demographics
NPI:1912336413
Name:FULLER, RUSSELL F I (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:F
Last Name:FULLER
Suffix:I
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 EXECUTIVE SQ
Mailing Address - Street 2:SUITE 1110
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9122
Mailing Address - Country:US
Mailing Address - Phone:858-558-7707
Mailing Address - Fax:858-558-7708
Practice Address - Street 1:4225 EXECUTIVE SQ
Practice Address - Street 2:SUITE 1110
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9122
Practice Address - Country:US
Practice Address - Phone:858-558-7707
Practice Address - Fax:858-558-7708
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16530103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical