Provider Demographics
NPI:1912678863
Name:FULLER, BRENT (ASW)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3881 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-1105
Mailing Address - Country:US
Mailing Address - Phone:626-630-7337
Mailing Address - Fax:
Practice Address - Street 1:3881 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90062-1105
Practice Address - Country:US
Practice Address - Phone:626-630-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA118763104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker