Provider Demographics
NPI:1245378835
Name:MAXIMOV, SHANNON NICOLE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:NICOLE
Last Name:MAXIMOV
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:NICOLE
Other - Last Name:ELKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:900 N WESTMORELAND RD STE 114
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1680
Mailing Address - Country:US
Mailing Address - Phone:312-695-7542
Mailing Address - Fax:312-694-2535
Practice Address - Street 1:900 N WESTMORELAND RD STE 114
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1680
Practice Address - Country:US
Practice Address - Phone:312-695-7542
Practice Address - Fax:312-694-2535
Is Sole Proprietor?:No
Enumeration Date:2007-02-03
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490232931041C0700X
ORL62261041C0700X
CAASW # 183631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical