Provider Demographics
NPI:1518220623
Name:STULL, LAURA GRACE (PHD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:GRACE
Last Name:STULL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:GRACE
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3565 ALBATROSS ST
Mailing Address - Street 2:APT 4
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4837
Mailing Address - Country:US
Mailing Address - Phone:574-361-2114
Mailing Address - Fax:
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:116B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0002
Practice Address - Country:US
Practice Address - Phone:858-242-8066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist