Provider Demographics
NPI:1831979087
Name:FULLER THEOLOGICAL SEMINARY
Entity type:Organization
Organization Name:FULLER THEOLOGICAL SEMINARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TED
Authorized Official - Middle Name:
Authorized Official - Last Name:COSSE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:818-939-3280
Mailing Address - Street 1:155 S DE LACEY AVE APT 1004
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-4521
Mailing Address - Country:US
Mailing Address - Phone:818-939-3280
Mailing Address - Fax:
Practice Address - Street 1:1110 E MISSOURI AVE STE 850
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2733
Practice Address - Country:US
Practice Address - Phone:602-613-1725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty