Provider Demographics
NPI:1245753847
Name:TYTENICZ, SHANE L
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:L
Last Name:TYTENICZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E DELAWARE PL
Mailing Address - Street 2:UNIT 1601
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-1479
Mailing Address - Country:US
Mailing Address - Phone:312-504-8463
Mailing Address - Fax:
Practice Address - Street 1:40 E DELAWARE PL
Practice Address - Street 2:UNIT 1601
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2014
Practice Address - Country:US
Practice Address - Phone:224-307-4697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral