Provider Demographics
NPI:1851805626
Name:TULLER, BROCK (LMFT)
Entity Type:Individual
Prefix:MR
First Name:BROCK
Middle Name:
Last Name:TULLER
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11278 LOS ALAMITOS BLVD # 317
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3958
Mailing Address - Country:US
Mailing Address - Phone:559-301-7507
Mailing Address - Fax:
Practice Address - Street 1:1370 BREA BLVD STE 132
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4123
Practice Address - Country:US
Practice Address - Phone:559-301-7507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF91276106H00000X
CALMFT117211106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist