Provider Demographics
NPI:1417026022
Name:THE SHEKINAH TRIAD PC
Entity Type:Organization
Organization Name:THE SHEKINAH TRIAD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:JOANNE
Authorized Official - Last Name:NADULEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-220-1331
Mailing Address - Street 1:2016 N KENNICOTT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-2922
Mailing Address - Country:US
Mailing Address - Phone:847-220-1331
Mailing Address - Fax:847-398-3099
Practice Address - Street 1:2016 N KENNICOTT
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-2922
Practice Address - Country:US
Practice Address - Phone:847-220-1331
Practice Address - Fax:847-398-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490089991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILMN92640904PMedicare ID - Type UnspecifiedPART C EARLY INTERVENTION