Provider Demographics
NPI:1235669235
Name:FULLILOVE, MARCELLA (MS QMHP)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:
Last Name:FULLILOVE
Suffix:
Gender:F
Credentials:MS QMHP
Other - Prefix:
Other - First Name:MARCELLA
Other - Middle Name:
Other - Last Name:FULLILOVE-PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:IL
Mailing Address - Zip Code:62995-1328
Mailing Address - Country:US
Mailing Address - Phone:618-658-3079
Mailing Address - Fax:618-658-2501
Practice Address - Street 1:1401 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:IL
Practice Address - Zip Code:62914-1810
Practice Address - Country:US
Practice Address - Phone:618-734-2665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health