Provider Demographics
NPI:1558997981
Name:FULLER, ELIZABETH ASHLEY (PHD, BCBA)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ASHLEY
Last Name:FULLER
Suffix:
Gender:F
Credentials:PHD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 18TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811-6753
Mailing Address - Country:US
Mailing Address - Phone:925-487-8019
Mailing Address - Fax:
Practice Address - Street 1:1618 18TH ST APT 4
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-6753
Practice Address - Country:US
Practice Address - Phone:925-487-8019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABACB299748103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst