Provider Demographics
NPI:1982015384
Name:FULLER, SHERRY
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:
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 1:22424 ARQUILLA DR
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1537
Mailing Address - Country:US
Mailing Address - Phone:708-321-0365
Mailing Address - Fax:
Practice Address - Street 1:2423 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5483
Practice Address - Country:US
Practice Address - Phone:815-725-9992
Practice Address - Fax:815-725-9993
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146011847235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist