Provider Demographics
NPI:1750062824
Name:FULLER, WILLIAM JOHNSON IV
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOHNSON
Last Name:FULLER
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BUTTERFIELD RD STE 1600
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 FOXBANK PLANTATION BLVD STE E
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-6741
Practice Address - Country:US
Practice Address - Phone:843-761-4622
Practice Address - Fax:803-759-8002
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT40202225100000X
SC225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist