Healthcare Provider Details

I. General information

NPI: 1679407456
Provider Name (Legal Business Name): RYAN FULLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

466 E MAIN ST
MIDDLETOWN NY
10940-2534
US

IV. Provider business mailing address

466 E MAIN ST
MIDDLETOWN NY
10940-2534
US

V. Phone/Fax

Practice location:
  • Phone: 845-843-6400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number018022
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: