Basic Information
Provider Information | |||||||||
NPI: | 1932657160 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHARE | ||||||||
FirstName: | ADAM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSY.D., LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 32 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | PARK RIDGE | ||||||||
State: | IL | ||||||||
PostalCode: | 600684060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8478234444 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 32 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | PARK RIDGE | ||||||||
State: | IL | ||||||||
PostalCode: | 600684060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8478234444 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2016 | ||||||||
LastUpdateDate: | 09/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 178.012302 | IL | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 01633134 | 01 |   | BC GROUP ID | OTHER | 212481 | 01 |   | GROUP PTAN | OTHER | 1235100140 | 01 |   | GROUP NPI | OTHER |