Provider Demographics
NPI:1043795677
Name:SHAH, POOJA RAJESH
Entity Type:Individual
Prefix:
First Name:POOJA
Middle Name:RAJESH
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N JEFFERSON ST APT 604
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-1199
Mailing Address - Country:US
Mailing Address - Phone:214-476-9690
Mailing Address - Fax:
Practice Address - Street 1:30 N MICHIGAN AVE STE 1320
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3720
Practice Address - Country:US
Practice Address - Phone:312-470-4302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166001568106H00000X
390200000X
CAAMFT118089101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health