Provider Demographics
NPI:1578018172
Name:SHAN, LESLIE K (MS)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:K
Last Name:SHAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:K
Other - Last Name:ALLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11020 STATE ROUTE 250
Mailing Address - Street 2:PO BOX 516
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439
Mailing Address - Country:US
Mailing Address - Phone:618-943-3754
Mailing Address - Fax:618-943-3657
Practice Address - Street 1:11020 STATE ROUTE 250
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439
Practice Address - Country:US
Practice Address - Phone:618-943-3754
Practice Address - Fax:618-943-3657
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL376003178 (008)Medicaid
ILC 48402Medicare UPIN
IL207184Medicare PIN