MEDICARE: RICHARD DANIEL 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	103G00000X	Clinical Neuropsychologist	441	AK
2	103TB0200X	Cognitive & Behavioral Psychologist	441	AK
3	103TC0700X	Clinical Psychologist	441	AK
4	103TC2200X	Clinical Child & Adolescent Psychologist	441	AK
5	103TF0200X	Forensic Psychologist	441	AK
6	103TA0700X	Adult Development & Aging Psychologist	441	AK
7	103T00000X	Psychologist	441	AK
8	103TM1800X	Intellectual & Developmental Disabilities Psychologist	441	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	51478	OTHER	DC	NATIONAL REGISTER-PSYCHOL
3	441	OTHER	AK	PSYCHOLOGIST LICENSE

General Provider Information

NPI Number	:	1578572947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD DANIEL FULLER PHD

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	03/22/2012

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