Basic Information
| Provider Information | |||||||||
| NPI: | 1427235274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHRISTINE | ||||||||
| FirstName: | SHELL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LCPC CRADC NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8212 ANCHOR DRIVE | ||||||||
| Address2: | #501 | ||||||||
| City: | WOODRIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083083721 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1414 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601603902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087868541 | ||||||||
| FaxNumber: | 7086813958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2008 | ||||||||
| LastUpdateDate: | 12/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 13056 | IL | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 75018 | IL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 180006736 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.