Provider Demographics
NPI:1831542315
Name:FULLER, ROXANNE MARIE (LMFT)
Entity type:Individual
Prefix:MS
First Name:ROXANNE
Middle Name:MARIE
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 1:1715 JAY ST
Mailing Address - Street 2:APT. D
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-1254
Mailing Address - Country:US
Mailing Address - Phone:510-774-5225
Mailing Address - Fax:
Practice Address - Street 1:925 ADAMS ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-2021
Practice Address - Country:US
Practice Address - Phone:510-774-5225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT80498106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist