Provider Demographics
NPI:1669721684
Name:BROWN FULLER, ELISA (PHD)
Entity type:Individual
Prefix:DR
First Name:ELISA
Middle Name:
Last Name:BROWN FULLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:MARIE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10736 JEFFERSON BLVD # 412
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4933
Mailing Address - Country:US
Mailing Address - Phone:310-295-9528
Mailing Address - Fax:
Practice Address - Street 1:25550 HAWTHORNE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6832
Practice Address - Country:US
Practice Address - Phone:310-295-9528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY32819103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7068Medicaid
CA7420Medicaid