Provider Demographics
NPI:1639830052
Name:FULLER, SAMANTHA LEIGH
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEIGH
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 1:19691 MARINO PLZ
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-3536
Mailing Address - Country:US
Mailing Address - Phone:562-544-6984
Mailing Address - Fax:
Practice Address - Street 1:160 S OLD SPRINGS RD STE 135
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92808-1285
Practice Address - Country:US
Practice Address - Phone:657-202-6464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician