Provider Demographics
NPI:1538750138
Name:FULLERTON COMMUNITY COUNSELING
Entity type:Organization
Organization Name:FULLERTON COMMUNITY COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LMFT
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-655-5371
Mailing Address - Street 1:1636 VICTORIA DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-2939
Mailing Address - Country:US
Mailing Address - Phone:714-655-5371
Mailing Address - Fax:
Practice Address - Street 1:2701 E CHAPMAN AVE STE 203
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3751
Practice Address - Country:US
Practice Address - Phone:714-655-5371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty