MEDICARE: FULLER DIAGNOSTICS, LLC

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	103TB0200X	Cognitive & Behavioral Psychologist
2	103TC0700X	Clinical Psychologist
3	103TC2200X	Clinical Child & Adolescent Psychologist
4	103TF0200X	Forensic Psychologist
5	103TM1800X	Intellectual & Developmental Disabilities Psychologist
6	103T00000X	Psychologist
7	103TP2701X	Group Psychotherapy Psychologist
8	1041C0700X	Clinical Social Worker	1022	AK
9	1041C0700X	Clinical Social Worker	1023	AK
10	103G00000X	Clinical Neuropsychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	441	OTHER	AK	STATE LICENSE RICHARD FULLER
2	1194029488	OTHER		NPI KRISTA PEMBERTON LCSW
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	51470	OTHER	AK	NATNL REG-KRISTI FULLER
6	51478	OTHER	AK	NATNL REG-RICHARD FULLER
7	1700865029	OTHER	AK	NPI KRISTI FULLER
8	1022	OTHER	AK	STATE LICENSE MAUREEN YOUNG
9	1023	OTHER	AK	STATE LICENSE KRISTA PEMBERTON
10	1578572947	OTHER	AK	NPI RICHARD FULLER
11	1821392119	OTHER		NPI MAUREEN YOUNG LCSW
12	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
13	436	OTHER	AK	STATE LICENSE KRISTI FULLER

General Provider Information

NPI Number	:	1326152711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULLER DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 92303
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99509-2303
Country	:	US
Telephone Number	:	907-561-0552
Fax Number	:	907-561-0562

Provider Business Practice Location Address
First Line	:	2600 DENALI ST
Second Line	:	SUITE 450
City	:	ANCHORAGE
State	:	AK
Zip	:	99503-2746
Country	:	US
Telephone Number	:	907-561-0552
Fax Number	:	907-561-0562

Authorized Official
Title or Position	:	OWNER/PARTNER
Name	:	KRISTI H FULLER
Credential	:	PHD, ABPP-CN
Telephone Number	:	907-561-0552

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	03/22/2012

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1700865029 — DR. KRISTI H FULLER PHD, ABPP-CN
Practice Location Address:

2600 DENALI ST , SUITE 450
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99503-2746

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Practice Fax: 907-561-0562

1548289846 — DAVID R SAMSON M.D., DLFAPA
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1578572947 — RICHARD DANIEL FULLER PHD
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1811169634 — ROBERT THOMAS ROSELIUS O.D.
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