Provider Demographics
NPI:1235220369
Name:SHEA, KATHLEEN V (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:V
Last Name:SHEA
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 1:42258 N CRAWFORD RD
Mailing Address - Street 2:A-1
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-9570
Mailing Address - Country:US
Mailing Address - Phone:847-217-7660
Mailing Address - Fax:847-395-9973
Practice Address - Street 1:42258 N CRAWFORD RD
Practice Address - Street 2:A-1
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-9570
Practice Address - Country:US
Practice Address - Phone:847-217-7660
Practice Address - Fax:847-395-9973
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003133103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0497205371OtherBCBS