MEDICARE: CONSTANCE FULLILOVE, PH.D., LTD.

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		IL

General Provider Information

NPI Number	:	1851441984
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONSTANCE FULLILOVE, PH.D., LTD.

Provider Business Mailing Address
First Line	:	205 W RANDOLPH ST
Second Line	:	SUITE 830
City	:	CHICAGO
State	:	IL
Zip	:	60606-1867
Country	:	US
Telephone Number	:	312-560-1808
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 W RANDOLPH ST
Second Line	:	SUITE 830
City	:	CHICAGO
State	:	IL
Zip	:	60606-1867
Country	:	US
Telephone Number	:	312-560-1808
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	DR. CONSTANCE ANITA FULLILOVE
Credential	:	PH.D.
Telephone Number	:	312-560-1808

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	08/22/2020

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