Provider Demographics
NPI:1932526563
Name:FULLER, KELSEY (LCSW)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 S EL CAMINO REAL
Mailing Address - Street 2:SUITE #200
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2380
Mailing Address - Country:US
Mailing Address - Phone:650-393-8904
Mailing Address - Fax:
Practice Address - Street 1:2600 S EL CAMINO REAL
Practice Address - Street 2:SUITE #200
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2380
Practice Address - Country:US
Practice Address - Phone:650-393-8904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-20
Last Update Date:2017-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA668201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health