Provider Demographics
NPI:1043227473
Name:FULTON, LEAH MAE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:MAE
Last Name:FULTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:LEAH
Other - Middle Name:MAE
Other - Last Name:KRUDOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1312 DORCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-1054
Mailing Address - Country:US
Mailing Address - Phone:847-949-0983
Mailing Address - Fax:
Practice Address - Street 1:205 W WACKER DR
Practice Address - Street 2:SUIE 820
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-1216
Practice Address - Country:US
Practice Address - Phone:312-640-0329
Practice Address - Fax:847-375-8357
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-009674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist