Healthcare Provider Details

I. General information

NPI: 1245508688
Provider Name (Legal Business Name): ALESIA NESIE FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4129 MAIN ST. SUITE 202
RIVERSIDE CA
92501
US

IV. Provider business mailing address

4129 MAIN ST. SUITE 202
RIVERSIDE CA
92501
US

V. Phone/Fax

Practice location:
  • Phone: 909-244-6159
  • Fax: 951-443-3714
Mailing address:
  • Phone: 909-244-6159
  • Fax: 951-443-3714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number25712
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number25712
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number25712
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: