Provider Demographics
NPI:1487821690
Name:FULLER, WILLIAM SHAW (MA, LMFT)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:SHAW
Last Name:FULLER
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S B ST
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-6933
Mailing Address - Country:US
Mailing Address - Phone:805-735-4376
Mailing Address - Fax:805-737-3251
Practice Address - Street 1:101 S B ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6933
Practice Address - Country:US
Practice Address - Phone:805-735-4376
Practice Address - Fax:805-737-3251
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA37ABMedicaid