Provider Demographics
NPI:1871712653
Name:FULLER, J. RYAN (PHD)
Entity type:Individual
Prefix:
First Name:J. RYAN
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 3RD AVE
Mailing Address - Street 2:SUITE 505
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-4731
Mailing Address - Country:US
Mailing Address - Phone:646-495-3078
Mailing Address - Fax:
Practice Address - Street 1:909 THIRD AVE.
Practice Address - Street 2:SUITE 505 NEW YORK BEHAVIORAL HEALTH,
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022
Practice Address - Country:US
Practice Address - Phone:646-495-3078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017108103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist