Provider Demographics
NPI:1164743936
Name:TAVAKOLI, SHEDEH (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHEDEH
Middle Name:
Last Name:TAVAKOLI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 W. FOSTER
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-6971
Mailing Address - Country:US
Mailing Address - Phone:248-736-0173
Mailing Address - Fax:
Practice Address - Street 1:3420 W FOSTER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-6971
Practice Address - Country:US
Practice Address - Phone:312-813-0160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007463101YP2500X
MI6401008389101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional