MEDICARE: SARAH B FULTZ

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
1	106H00000X	Marriage & Family Therapist	140527	CA
2	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1669133948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH B FULTZ

Provider Business Mailing Address
First Line	:	1 BOARDWALK AVE STE 210
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91360-5766
Country	:	US
Telephone Number	:	805-285-3432
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 BOARDWALK AVE STE 210
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91360-5766
Country	:	US
Telephone Number	:	805-285-3432
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2022
Last Update Date	:	06/12/2024

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