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General NPI Number Information
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NPI Number | 1669721684
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Entity Type | Individual
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Provider Name | ELISA BROWN FULLER PHD
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Gender | Female
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Dates
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Enumeration Date | 09/05/2012
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Last Update Date | 10/24/2025
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Provider Practice Location Address
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Address Line | 5880 SAN VICENTE BLVD STE 103
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City | LOS ANGELES
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State | CA
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Zip | 90019-6667
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Country | US
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Telephone | 310-295-9571
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Fax |
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Provider Business Mailing Address
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Address Line | 10736 JEFFERSON BLVD # 412
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City | CULVER CITY
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State | CA
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Zip | 90230-4933
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Country | US
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Telephone | 310-295-9528
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY32819
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License Number State | CA
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