Provider Demographics
NPI:1093044653
Name:FULLER-POLHAMUS, LAURA ASHLEY (PSYD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ASHLEY
Last Name:FULLER-POLHAMUS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 W END AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-1816
Mailing Address - Country:US
Mailing Address - Phone:908-333-4646
Mailing Address - Fax:
Practice Address - Street 1:134 W END AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-1816
Practice Address - Country:US
Practice Address - Phone:908-333-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ5909103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program