=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053979278
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FULLER LIFE CONCEPTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2019
-----------------------------------------------------
Last Update Date | 06/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5150 CANDLEWOOD ST STE 18C
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90712-1927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-334-0064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7402
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90807-0402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-334-0064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KIM FULLER
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 323-336-2294
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------