Provider Demographics
NPI:1770200511
Name:FULLER, K'CHELLE MARI (SUD)
Entity type:Individual
Prefix:
First Name:K'CHELLE
Middle Name:MARI
Last Name:FULLER
Suffix:
Gender:F
Credentials:SUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 THORNTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-3734
Mailing Address - Country:US
Mailing Address - Phone:510-792-4357
Mailing Address - Fax:
Practice Address - Street 1:6330 THORNTON AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-3734
Practice Address - Country:US
Practice Address - Phone:510-792-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 172V00000X
CA13722101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No172V00000XOther Service ProvidersCommunity Health Worker