Provider Demographics
NPI:1780619585
Name:FULLER, STEPHANIE (LMFT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
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:PO BOX 1492
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93423-1492
Mailing Address - Country:US
Mailing Address - Phone:805-235-3691
Mailing Address - Fax:805-461-0620
Practice Address - Street 1:4555 EL CAMINO REAL STE G
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-2700
Practice Address - Country:US
Practice Address - Phone:805-235-3691
Practice Address - Fax:805-461-0620
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39582106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist