Healthcare Provider Details

I. General information

NPI: 1053260927
Provider Name (Legal Business Name): GIGI LEGEIA FULLER CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2026
Last Update Date: 01/26/2026
Certification Date: 01/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N SANGAMON ST
CHICAGO IL
60607-2202
US

IV. Provider business mailing address

601 S 3RD AVE
MAYWOOD IL
60153-2232
US

V. Phone/Fax

Practice location:
  • Phone: 312-493-5990
  • Fax: 312-493-5990
Mailing address:
  • Phone: 312-493-5990
  • Fax: 312-493-5990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22296
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: