Provider Demographics
NPI:1326152711
Name:FULLER DIAGNOSTICS, LLC
Entity type:Organization
Organization Name:FULLER DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:H
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, ABPP-CN
Authorized Official - Phone:907-561-0552
Mailing Address - Street 1:PO BOX 92303
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99509-2303
Mailing Address - Country:US
Mailing Address - Phone:907-561-0552
Mailing Address - Fax:907-561-0562
Practice Address - Street 1:2600 DENALI ST
Practice Address - Street 2:SUITE 450
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2746
Practice Address - Country:US
Practice Address - Phone:907-561-0552
Practice Address - Fax:907-561-0562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X, 103TC0700X, 103TC2200X, 103TF0200X, 103TM1800X, 103T00000X, 103TP2701X, 103G00000X
AK10221041C0700X
AK10231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK441OtherSTATE LICENSE RICHARD FULLER
1194029488OtherNPI KRISTA PEMBERTON LCSW
AKPS8574Medicaid
AKPSG123Medicaid
AK51470OtherNATNL REG-KRISTI FULLER
AK51478OtherNATNL REG-RICHARD FULLER
AK1700865029OtherNPI KRISTI FULLER
AK1022OtherSTATE LICENSE MAUREEN YOUNG
AK1023OtherSTATE LICENSE KRISTA PEMBERTON
AK1578572947OtherNPI RICHARD FULLER
1821392119OtherNPI MAUREEN YOUNG LCSW
AKPS04411Medicaid
AK436OtherSTATE LICENSE KRISTI FULLER
AK1578572947OtherNPI RICHARD FULLER
AK160671Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
AKPSG123Medicaid
163672Medicare PIN