Healthcare Provider Details

I. General information

NPI: 1932022134
Provider Name (Legal Business Name): CONSTANCE A. FULLILOVE, PH.D. LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4742 S ELLIS AVE APT 1
CHICAGO IL
60615-1821
US

IV. Provider business mailing address

4742 S ELLIS AVE APT 1
CHICAGO IL
60615-1821
US

V. Phone/Fax

Practice location:
  • Phone: 312-560-1808
  • Fax:
Mailing address:
  • Phone: 312-560-1808
  • 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: CONSTANCE A. FULLILOVE, PH.D. LTD
Title or Position: OWNER
Credential: PH.D.
Phone: 312-560-1808