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General NPI Number Information
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NPI Number | 1437325040
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Entity Type | Organization
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Legal Business Name | FULLER PSYCHOLOGY CORPORATION
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Dates
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Enumeration Date | 05/03/2008
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Last Update Date | 05/03/2008
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Provider Practice Location Address
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Address Line | 4225 EXECUTIVE SQ SUITE 1110
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City | LA JOLLA
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State | CA
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Zip | 92037-9122
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Country | US
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Telephone | 858-558-7707
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Fax | 858-558-7708
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Provider Business Mailing Address
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Address Line | 4225 EXECUTIVE SQ SUITE 1110
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City | LA JOLLA
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State | CA
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Zip | 92037-9122
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Country | US
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Telephone | 858-558-7707
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Fax | 858-558-7708
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Authorized Official
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Title or Position | PRESIDENT, CLINICAL PSYCHOLOGIST
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Name | DR. RUSSELL F FULLER
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Credential | PSY.D.
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Telephone | 858-558-7707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY16530
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License Number State | CA
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