Healthcare Provider Details

I. General information

NPI: 1194231977
Provider Name (Legal Business Name): SARAH FULLILOVE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2017
Last Update Date: 12/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 REGENCY DR E STE A
SAVOY IL
61874-9312
US

IV. Provider business mailing address

1401 REGENCY DR E STE A
SAVOY IL
61874-9312
US

V. Phone/Fax

Practice location:
  • Phone: 217-722-2909
  • Fax:
Mailing address:
  • Phone: 217-722-2909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.009957
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: