1588775332 NPI number — SHELLEA SWAN LCPC

Table of content: SHELLEA SWAN LCPC (NPI 1588775332)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588775332 NPI number — SHELLEA SWAN LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SWAN
Provider First Name:
SHELLEA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588775332
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28596 WINDMERE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE BLUFF
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60044-3002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-226-0580
Provider Business Mailing Address Fax Number:
847-748-7478

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 EAST WISCONSIN AVE
Provider Second Line Business Practice Location Address:
SUITE 203B
Provider Business Practice Location Address City Name:
LAKE FOREST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-226-0580
Provider Business Practice Location Address Fax Number:
847-748-7478
Provider Enumeration Date:
08/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  180006144 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X , with the licence number: LH60227172 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)