Healthcare Provider Details

I. General information

NPI: 1508316829
Provider Name (Legal Business Name): SIERRA RUTH FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 SALEM ST
MEDFORD MA
02155-3308
US

IV. Provider business mailing address

345 SALEM ST
MEDFORD MA
02155-3308
US

V. Phone/Fax

Practice location:
  • Phone: 508-789-9986
  • Fax:
Mailing address:
  • Phone: 508-789-9986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number122888
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: