Basic Information
| Provider Information | |||||||||
| NPI: | 1982813150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193538978 | ||||||||
| FaxNumber: | 3193848843 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193538978 | ||||||||
| FaxNumber: | 3193848843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 10/03/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 316 | MT | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 001276 | IA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0492099 | 05 | MT | MEDICAID |