Healthcare Provider Details

I. General information

NPI: 1699485367
Provider Name (Legal Business Name): AFSANEH ROSHANGAH FULLER PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23437 KILTY PL
WEST HILLS CA
91307-1422
US

IV. Provider business mailing address

6520 PLATT AVE # 281
WEST HILLS CA
91307-3218
US

V. Phone/Fax

Practice location:
  • Phone: 818-914-9654
  • Fax:
Mailing address:
  • Phone: 818-914-9654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number33765
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: