Basic Information
| Provider Information | |||||||||
| NPI: | 1245378835 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAXIMOV | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ELKINS | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 900 N WESTMORELAND RD STE 114 | ||||||||
| Address2: | |||||||||
| City: | LAKE FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600451680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126957542 | ||||||||
| FaxNumber: | 3126942535 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 N WESTMORELAND RD STE 114 | ||||||||
| Address2: | |||||||||
| City: | LAKE FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600451680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126957542 | ||||||||
| FaxNumber: | 3126942535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2007 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149023293 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.