Provider Demographics
NPI:1124528104
Name:AJIFU - TULLY, SARA (LCSW)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:AJIFU - TULLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:AJIFU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:11170 WARNER AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4014
Mailing Address - Country:US
Mailing Address - Phone:714-966-8171
Mailing Address - Fax:
Practice Address - Street 1:17100 EUCLID ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4004
Practice Address - Country:US
Practice Address - Phone:714-966-8171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA808921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical