Provider Demographics
NPI:1134646219
Name:NIVASCH, SHARI BETH
Entity Type:Individual
Prefix:
First Name:SHARI
Middle Name:BETH
Last Name:NIVASCH
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 1:445 BEVERLY DR
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3012
Mailing Address - Country:US
Mailing Address - Phone:847-542-0115
Mailing Address - Fax:
Practice Address - Street 1:445 BEVERLY DRIVE
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091
Practice Address - Country:US
Practice Address - Phone:847-542-0115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.005481101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional