1639581978 NPI number — SHELLEY PRENDERGAST LCPC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639581978 NPI number — SHELLEY PRENDERGAST LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRENDERGAST
Provider First Name:
SHELLEY
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:
1639581978
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1120 E MAIN ST
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
ST CHARLES
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60174-2287
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-377-6613
Provider Business Mailing Address Fax Number:
630-377-6225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 E COUNTRYSIDE PKWY
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
YORKVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60560-1813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-553-1600
Provider Business Practice Location Address Fax Number:
630-553-7993
Provider Enumeration Date:
05/21/2014

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: 101YP2500X , with the licence number:  178008965 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 180009302 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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