Healthcare Provider Details

I. General information

NPI: 1669133948
Provider Name (Legal Business Name): SARAH B FULTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BOARDWALK AVE STE 210
THOUSAND OAKS CA
91360-5766
US

IV. Provider business mailing address

1 BOARDWALK AVE STE 210
THOUSAND OAKS CA
91360-5766
US

V. Phone/Fax

Practice location:
  • Phone: 805-285-3432
  • Fax:
Mailing address:
  • Phone: 805-285-3432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number140527
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: