Basic Information
| Provider Information | |||||||||
| NPI: | 1942634191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IBRAHIM | ||||||||
| FirstName: | SHADIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6741 PORTAGE AVE | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463682432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197307572 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1441 E 84TH PL | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464106451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197942000 | ||||||||
| FaxNumber: | 2197942010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2013 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 39002451A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.