Provider Demographics
NPI:1114329919
Name:FULLER, LAURA MARIE (MFT INTERN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:FULLER
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1849 SAWTELLE BLVD
Mailing Address - Street 2:#100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-7006
Mailing Address - Country:US
Mailing Address - Phone:310-478-8305
Mailing Address - Fax:
Practice Address - Street 1:1849 SAWTELLE BLVD
Practice Address - Street 2:#100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7006
Practice Address - Country:US
Practice Address - Phone:310-478-8305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist