Provider Demographics
NPI:1194113407
Name:FULLER, LASHONDA (PHD)
Entity type:Individual
Prefix:DR
First Name:LASHONDA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5454 S SHORE DR
Mailing Address - Street 2:APT. 101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-5919
Mailing Address - Country:US
Mailing Address - Phone:313-649-5008
Mailing Address - Fax:
Practice Address - Street 1:9510 S CONSTANCE AVE
Practice Address - Street 2:SUITE C-6
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4700
Practice Address - Country:US
Practice Address - Phone:872-221-0041
Practice Address - Fax:866-683-7047
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010632101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional