Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst |
NPI | 1003110628 |
---|---|
Provider Name | Victor P Fuller |
First Address | South Holland, IL 60473-3233 |
Second Address | Flossmoor, IL 60422-1778 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/12/2010 |
Last Update Date | 23/12/2010 |