Provider Demographics
NPI:1548381569
Name:FULLER, ANDREA (MFT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFIC GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:93950-4264
Mailing Address - Country:US
Mailing Address - Phone:831-236-5930
Mailing Address - Fax:
Practice Address - Street 1:621 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PACIFIC GROVE
Practice Address - State:CA
Practice Address - Zip Code:93950-4264
Practice Address - Country:US
Practice Address - Phone:831-236-5930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30362106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist