Provider Demographics
NPI:1780632356
Name:FULLER, SHARON ANN (MA,MFT)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:ANN
Last Name:FULLER
Suffix:
Gender:F
Credentials:MA,MFT
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:ANN
Other - Last Name:MATTHEWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2850 MESA VERDE DR E
Mailing Address - Street 2:SUITE H
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4891
Mailing Address - Country:US
Mailing Address - Phone:714-437-5013
Mailing Address - Fax:714-437-5015
Practice Address - Street 1:2850 MESA VERDE DR E
Practice Address - Street 2:SUITE H
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4891
Practice Address - Country:US
Practice Address - Phone:714-437-5013
Practice Address - Fax:714-437-5015
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC31518106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist