Provider Demographics
NPI:1861262008
Name:FULLYLOVE, SAMAIYAH
Entity type:Individual
Prefix:
First Name:SAMAIYAH
Middle Name:
Last Name:FULLYLOVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-5241
Mailing Address - Country:US
Mailing Address - Phone:602-842-3130
Mailing Address - Fax:
Practice Address - Street 1:1855 E SOUTHERN AVE STE 111
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5227
Practice Address - Country:US
Practice Address - Phone:602-842-3130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22423101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health