Provider Demographics
NPI:1508305376
Name:WANG, SHAOXUAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SHAOXUAN
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LOLA
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:3605 W FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-4310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3605 W FILLMORE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-4310
Practice Address - Country:US
Practice Address - Phone:312-618-0135
Practice Address - Fax:773-588-7762
Is Sole Proprietor?:No
Enumeration Date:2017-02-14
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0210481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0439 0054Medicaid