Provider Demographics
NPI:1740961259
Name:FULLER, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
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 1:605 HILLCREST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-4123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3105 N WILKE RD STE H
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-1450
Practice Address - Country:US
Practice Address - Phone:847-255-8690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242007385235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist