Basic Information
| Provider Information | |||||||||
| NPI: | 1447751292 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MT-BC, NMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 WOODSTOCK RD | ||||||||
| Address2: | |||||||||
| City: | NORTH ANDOVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018454358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786095037 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021191042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174428800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2018 | ||||||||
| LastUpdateDate: | 02/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225A00000X | 13573 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Music Therapist |
No ID Information.