Provider Demographics
NPI:1467988170
Name:FULLER, ILEA (LPC, CAADC)
Entity Type:Individual
Prefix:
First Name:ILEA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:LPC, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25901 E PINE ST
Mailing Address - Street 2:
Mailing Address - City:CALUMET
Mailing Address - State:MI
Mailing Address - Zip Code:49913-1257
Mailing Address - Country:US
Mailing Address - Phone:906-369-3949
Mailing Address - Fax:
Practice Address - Street 1:540 DEPOT ST
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-2031
Practice Address - Country:US
Practice Address - Phone:906-482-7282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI6401019086101YM0800X
MIC-03721101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health