Active NPI
Brian Jay Fuller, PH.D.
- Psychologist
- Portage, MI
National Provider Identifier
1942258595
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- 6301013172
- Practice address
- 1662 E Centre Ave
Portage, MI 49002-4410 - Phone
- (269) 321-8564
- NPI assigned
- May 5, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | 6301013172 | MI | Primary |
Addresses
Primary practice location
1662 E Centre Ave
Portage, MI 49002-4410
Mailing address
5340 Holiday Ter
Kalamazoo, MI 49009-2196
Phone (269) 321-8564
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 6301013172 | MI | MD | Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1146787200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1340064000000",
"number": "1942258595",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5340 HOLIDAY TER",
"city": "KALAMAZOO",
"state": "MI",
"postal_code": "490092196",
"telephone_number": "269-321-8564"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1662 E CENTRE AVE",
"city": "PORTAGE",
"state": "MI",
"postal_code": "490024410",
"telephone_number": "269-321-8564"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FULLER",
"first_name": "BRIAN",
"middle_name": "JAY",
"name_prefix": "Mr.",
"credential": "PH.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-05-05",
"last_updated": "2012-06-19",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "MI",
"license": "6301013172",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Portage, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 19, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.