Provider Demographics
NPI:1366915811
Name:FULLER, AMY LYNN (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:FULLER
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121 OLD BEAUMONT HWY
Mailing Address - Street 2:
Mailing Address - City:SILSBEE
Mailing Address - State:TX
Mailing Address - Zip Code:77656-6473
Mailing Address - Country:US
Mailing Address - Phone:406-656-8335
Mailing Address - Fax:
Practice Address - Street 1:2011 BROADWAY ST STE 130
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-5945
Practice Address - Country:US
Practice Address - Phone:281-997-8509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108990235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist