Provider Demographics
NPI:1699189993
Name:FULLER, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
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 1:325 W WASHINGTON ST STE 2 #3042
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1946
Mailing Address - Country:US
Mailing Address - Phone:619-244-1095
Mailing Address - Fax:
Practice Address - Street 1:3427 MISSION MESA WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-1555
Practice Address - Country:US
Practice Address - Phone:619-244-1095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2022-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist