Provider Demographics
NPI:1245508688
Name:FULLER, ALESIA NESIE
Entity type:Individual
Prefix:
First Name:ALESIA
Middle Name:NESIE
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 1:4129 MAIN ST.
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501
Mailing Address - Country:US
Mailing Address - Phone:909-244-6159
Mailing Address - Fax:951-443-3714
Practice Address - Street 1:4129 MAIN ST.
Practice Address - Street 2:SUITE 202
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501
Practice Address - Country:US
Practice Address - Phone:909-244-6159
Practice Address - Fax:951-443-3714
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25712103TC1900X, 103TE1100X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily