Basic Information
| Provider Information | |||||||||
| NPI: | 1073258893 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | MARY | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 SYLVAN AVE STE 2048 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD CLIFFS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076323165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6468736600 | ||||||||
| FaxNumber: | 6468594440 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 CANAL ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8572854520 | ||||||||
| FaxNumber: | 6468594440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2022 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-22-58856 | MA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.