Provider Demographics
NPI:1225991417
Name:FULLER, SOLOMON
Entity type:Individual
Prefix:
First Name:SOLOMON
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 STRATHMORE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-3164
Mailing Address - Country:US
Mailing Address - Phone:310-767-6213
Mailing Address - Fax:
Practice Address - Street 1:2301 BELLEVUE AVE FL 10
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-4017
Practice Address - Country:US
Practice Address - Phone:213-207-6561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-04
Last Update Date:2025-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT158800103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral