MEDICARE: DR. CONSTANCE ANITA FULLILOVE PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071-002239	IL

General Provider Information

NPI Number	:	1235209529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CONSTANCE ANITA FULLILOVE PH.D.

Provider Business Mailing Address
First Line	:	205 W RANDOLPH ST STE 830
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60606-1815
Country	:	US
Telephone Number	:	312-236-1498
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 W RANDOLPH ST STE 830
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60606-1815
Country	:	US
Telephone Number	:	312-236-1498
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	04/23/2021

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