Provider Demographics
NPI:1568180149
Name:FULLERTON, AARON (DPT)
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:
Last Name:FULLERTON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:517-435-3670
Practice Address - Street 1:16819 TORRENCE AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-6019
Practice Address - Country:US
Practice Address - Phone:708-394-5215
Practice Address - Fax:708-474-3853
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1366872225100000X
IL070026931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist