Provider Demographics
NPI:1336296540
Name:FULLER, CHARLOTTE
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 BOLINAS RD
Mailing Address - Street 2:APT. #6
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1968
Mailing Address - Country:US
Mailing Address - Phone:415-456-9350
Mailing Address - Fax:415-456-1508
Practice Address - Street 1:914 MISSION AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-6106
Practice Address - Country:US
Practice Address - Phone:415-457-6966
Practice Address - Fax:415-721-0281
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health