Provider Demographics
NPI:1881364206
Name:FULLERTON, PAMELA (MA, MED, LCPC)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:MA, MED, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7132 N HARLEM AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-1086
Mailing Address - Country:US
Mailing Address - Phone:847-701-4533
Mailing Address - Fax:
Practice Address - Street 1:7132 N HARLEM AVE STE 102
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-1086
Practice Address - Country:US
Practice Address - Phone:847-701-4533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional