Basic Information
| Provider Information | |||||||||
| NPI: | 1730382268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANAHAN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15300 WEST AVE STE 313 | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089237878 | ||||||||
| FaxNumber: | 7089237888 | ||||||||
| Practice Location | |||||||||
| Address1: | 15300 WEST AVE STE 313 | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089237878 | ||||||||
| FaxNumber: | 7089237888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 12/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149.010542 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 349643415001 | 05 | IL | MEDICAID | F400104844 | 01 | IL | MEDICARE PTAN | OTHER |