Provider Demographics
NPI:1568144988
Name:FULLER, ROCHELLE CLARA
Entity Type:Individual
Prefix:
First Name:ROCHELLE
Middle Name:CLARA
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1953 LANGLEY ST APT A
Mailing Address - Street 2:
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-1041
Mailing Address - Country:US
Mailing Address - Phone:312-613-7373
Mailing Address - Fax:
Practice Address - Street 1:2025 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5131
Practice Address - Country:US
Practice Address - Phone:847-360-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health