Provider Demographics
NPI:1063581007
Name:FULLER, BELEN CAMACHO (MSW)
Entity type:Individual
Prefix:MRS
First Name:BELEN
Middle Name:CAMACHO
Last Name:FULLER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MISS
Other - First Name:BELEN
Other - Middle Name:
Other - Last Name:CAMACHO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:PO BOX 83475
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90083-0475
Mailing Address - Country:US
Mailing Address - Phone:310-686-8280
Mailing Address - Fax:
Practice Address - Street 1:2323 W MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-2724
Practice Address - Country:US
Practice Address - Phone:323-293-5008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS194801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical