MEDICARE: CHERYL FULLER PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	23404	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0012JC	OTHER	TX	BLUE CROSS

General Provider Information

NPI Number	:	1750303269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERYL FULLER PHD

Provider Business Mailing Address
First Line	:	4320 BELLAIRE DR S APT 226W
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-5197
Country	:	US
Telephone Number	:	817-832-9329
Fax Number	:	817-924-1369

Provider Business Practice Location Address
First Line	:	1814 8TH AVE # B
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1354
Country	:	US
Telephone Number	:	817-735-8222
Fax Number	:	817-924-1369

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	08/25/2010

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