Provider Demographics
NPI:1013126036
Name:FULLER THEOLOGICAL SEMINARY
Entity type:Organization
Organization Name:FULLER THEOLOGICAL SEMINARY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THEOPOLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:COSSE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, MBA
Authorized Official - Phone:626-584-5566
Mailing Address - Street 1:180 NORTH OAKLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101
Mailing Address - Country:US
Mailing Address - Phone:626-584-5555
Mailing Address - Fax:626-584-5558
Practice Address - Street 1:180 NORTH OAKLAND AVENUE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1714
Practice Address - Country:US
Practice Address - Phone:626-584-5555
Practice Address - Fax:626-584-5558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
102L00000X, 103G00000X, 103TC0700X, 103TP2701X, 101YP1600X, 251S00000X
CA101YM0800X, 103T00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty