Healthcare Provider Details

I. General information

NPI: 1679255442
Provider Name (Legal Business Name): LUCAS LEE FULLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4748 STUDEBAKER RD
PLACERVILLE CA
95667-8605
US

IV. Provider business mailing address

900 FULTON AVE
SACRAMENTO CA
95825-8605
US

V. Phone/Fax

Practice location:
  • Phone: 530-906-3872
  • Fax:
Mailing address:
  • Phone: 916-484-3570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: