Healthcare Provider Details

I. General information

NPI: 1679269153
Provider Name (Legal Business Name): ALEXIS FULLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 S CANAL ST
CHICAGO IL
60607-5058
US

IV. Provider business mailing address

4115 W AERIE DR
TUCSON AZ
85741-2408
US

V. Phone/Fax

Practice location:
  • Phone: 520-487-1975
  • Fax:
Mailing address:
  • Phone: 702-752-6837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149031797
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: