Provider Demographics
NPI:1386281756
Name:FULLCHANGE, AILEEN (LP)
Entity type:Individual
Prefix:DR
First Name:AILEEN
Middle Name:
Last Name:FULLCHANGE
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2807 THROCKMORTON ST APT 101
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-6204
Mailing Address - Country:US
Mailing Address - Phone:510-685-8593
Mailing Address - Fax:
Practice Address - Street 1:3500 OAK LAWN AVE STE 230
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-4369
Practice Address - Country:US
Practice Address - Phone:214-247-6410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37995103TC2200X, 103TF0000X, 103TH0100X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service