Provider Demographics
NPI:1528611910
Name:FULCHER, TANISHA C
Entity type:Individual
Prefix:MRS
First Name:TANISHA
Middle Name:C
Last Name:FULCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TANISHA
Other - Middle Name:C
Other - Last Name:COWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2629
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91979
Mailing Address - Country:US
Mailing Address - Phone:619-794-5189
Mailing Address - Fax:
Practice Address - Street 1:8825 AERO DR.
Practice Address - Street 2:STE 315
Practice Address - City:SAN DIAGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:858-956-5901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT113338106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist