Provider Demographics
NPI:1609374685
Name:FULLEN, AILEEN
Entity Type:Individual
Prefix:
First Name:AILEEN
Middle Name:
Last Name:FULLEN
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 1:8960 ALBANY CT
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-9156
Mailing Address - Country:US
Mailing Address - Phone:734-223-3530
Mailing Address - Fax:
Practice Address - Street 1:512 BEACH ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3122
Practice Address - Country:US
Practice Address - Phone:810-629-4117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
MI235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist