Provider Demographics
NPI:1770653214
Name:FULLER, JOANNE (MFT-I)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:MFT-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-4023
Mailing Address - Country:US
Mailing Address - Phone:530-662-2211
Mailing Address - Fax:530-662-4315
Practice Address - Street 1:455 1ST ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-4023
Practice Address - Country:US
Practice Address - Phone:530-662-2211
Practice Address - Fax:530-662-4315
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF37246106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10010Medicaid