Healthcare Provider Details

I. General information

NPI: 1043140650
Provider Name (Legal Business Name): FULLRIEDE PROFESSIONAL COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2026
Last Update Date: 05/23/2026
Certification Date: 05/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 E EMPIRE ST # 110
BLOOMINGTON IL
61704-3630
US

IV. Provider business mailing address

2404 E EMPIRE ST STE 110
BLOOMINGTON IL
61704-3630
US

V. Phone/Fax

Practice location:
  • Phone: 815-584-6383
  • Fax:
Mailing address:
  • Phone: 815-584-6383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY FAE FULLRIEDE
Title or Position: PRESIDENT
Credential: LCPC
Phone: 815-584-6383