Provider Demographics
NPI:1750303269
Name:FULLER, CHERYL (PHD)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 BELLAIRE DR S APT 226W
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-5197
Mailing Address - Country:US
Mailing Address - Phone:817-832-9329
Mailing Address - Fax:817-924-1369
Practice Address - Street 1:1814 8TH AVE # B
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1354
Practice Address - Country:US
Practice Address - Phone:817-735-8222
Practice Address - Fax:817-924-1369
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23404103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0012JCOtherBLUE CROSS
TX8F1701Medicare PIN