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General NPI Number Information
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NPI Number | 1750946950
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Entity Type | Individual
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Provider Name | MATTHEW GERALD FULLER
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Gender | Male
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Dates
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Enumeration Date | 05/03/2019
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Last Update Date | 07/02/2024
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Provider Practice Location Address
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Address Line | 3601 THE VANDERBILT CLINIC
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City | NASHVILLE
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State | TN
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Zip | 37232-5428
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Country | US
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Telephone | 615-936-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 415 COUNTY ROAD 110 N
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City | MOUND
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State | MN
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Zip | 55364-8338
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Country | US
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Telephone | 386-795-9322
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 3369
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | IMH18270
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 6062
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License Number State | TN
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