MEDICARE: DR. WENDY P 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	103TC0700X	Clinical Psychologist	022384	NY

General Provider Information

NPI Number	:	1699285759
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WENDY P FULLER PHD

Provider Business Mailing Address
First Line	:	4401 BRONX BLVD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10470-1407
Country	:	US
Telephone Number	:	718-304-7015
Fax Number	:

Provider Business Practice Location Address
First Line	:	3317 ROCHAMBEAU AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10467-2846
Country	:	US
Telephone Number	:	718-470-8995
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2017
Last Update Date	:	09/09/2024

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