Provider Demographics
NPI:1831506377
Name:FULLER, DAVID DANIEL (LCSW79530)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:DANIEL
Last Name:FULLER
Suffix:
Gender:M
Credentials:LCSW79530
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 ARROYO RD
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-9650
Mailing Address - Country:US
Mailing Address - Phone:510-693-7403
Mailing Address - Fax:
Practice Address - Street 1:4951 ARROYO RD
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-9650
Practice Address - Country:US
Practice Address - Phone:510-693-7403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104100000X
CALCSW795301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker