Provider Demographics
NPI:1124667852
Name:FULLWOOD, NEIL
Entity type:Individual
Prefix:MR
First Name:NEIL
Middle Name:
Last Name:FULLWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 MARY AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-2210
Mailing Address - Country:US
Mailing Address - Phone:757-575-5221
Mailing Address - Fax:
Practice Address - Street 1:780 LYNNHAVEN PKWY STE 400
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7332
Practice Address - Country:US
Practice Address - Phone:877-418-2978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-28
Last Update Date:2019-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician