Provider Demographics
NPI:1831743970
Name:FULLER, TIFFANY I (SUDRC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:I
Last Name:FULLER
Suffix:
Gender:F
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 THE ALAMEDA STE 316
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-1461
Mailing Address - Country:US
Mailing Address - Phone:408-261-7777
Mailing Address - Fax:408-642-6052
Practice Address - Street 1:101 JOSE FIGUERES AVE STE 50
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-2068
Practice Address - Country:US
Practice Address - Phone:408-207-0560
Practice Address - Fax:408-642-6052
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108495104100000X
CAP0908161643101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8042OtherCADTP
CA8042Other1-IND