Provider Demographics
NPI:1285802157
Name:FULLERTON, SAMANTHA M (BCBA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:M
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 S WATT AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-6110
Mailing Address - Country:US
Mailing Address - Phone:916-706-2402
Mailing Address - Fax:
Practice Address - Street 1:2750 SUTTERVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-1024
Practice Address - Country:US
Practice Address - Phone:916-732-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator