Provider Demographics
NPI:1790507853
Name:FULLER, KALLI (LSW)
Entity type:Individual
Prefix:
First Name:KALLI
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 PARTRIDGE RUN DR
Mailing Address - Street 2:
Mailing Address - City:BRAIDWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60408-2304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:295 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416-1581
Practice Address - Country:US
Practice Address - Phone:708-515-0010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.114766101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health