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NPI Code Detail

MEDICARE: SAMANTHA LYNNE FULTS

MEDICARE: SAMANTHA LYNNE FULTS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106H00000XMarriage & Family Therapist148934CA

General Provider Information

NPI Number : 1528771581
Entity Type Code : Individual
Provider Name (Legal Business Name) : SAMANTHA LYNNE FULTS
Provider Business Mailing Address
First Line : 313 GRAND BLVD # 701
Second Line :
City : VENICE
State : CA
Zip : 90291-4234
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 21535 HAWTHORNE BLVD STE 102
Second Line :
City : TORRANCE
State : CA
Zip : 90503-6626
Country : US
Telephone Number : 310-817-2177
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/04/2023
Last Update Date : 08/28/2024

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