Provider Demographics
NPI:1235271644
Name:FULLERTON, MARY TAYLOR (MFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TAYLOR
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CHRISTINE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFTI
Mailing Address - Street 1:310 HARBOR BLVD BLDG E
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-4018
Mailing Address - Country:US
Mailing Address - Phone:650-802-6518
Mailing Address - Fax:
Practice Address - Street 1:310 HARBOR BLVD BLDG E
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-4018
Practice Address - Country:US
Practice Address - Phone:650-802-6518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46092106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist