Provider Demographics
NPI:1174077531
Name:FULLER BARTLETT, SAVANNAH (OTR/L, CHT)
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:
Last Name:FULLER BARTLETT
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:SAVANNAH
Other - Middle Name:
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:11050 MT BELVEDERE BLVD.
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5004
Mailing Address - Country:US
Mailing Address - Phone:315-774-6246
Mailing Address - Fax:
Practice Address - Street 1:11050 MT BELVEDERE BLVD.
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5004
Practice Address - Country:US
Practice Address - Phone:315-774-6246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020667225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist