Provider Demographics
NPI:1851839336
Name:FULLER, TRACEY
Entity Type:Individual
Prefix:
First Name:TRACEY
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 1:1600 W CAMPBELL AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1526
Mailing Address - Country:US
Mailing Address - Phone:408-871-4900
Mailing Address - Fax:
Practice Address - Street 1:1600 W CAMPBELL AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-1526
Practice Address - Country:US
Practice Address - Phone:408-871-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YP2500X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator