Provider Demographics
NPI:1598329179
Name:WELSH, SHANNON ANNE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ANNE
Last Name:WELSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4960 N MARINE DR APT 616
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3920
Mailing Address - Country:US
Mailing Address - Phone:773-307-2886
Mailing Address - Fax:
Practice Address - Street 1:4960 N MARINE DR APT 616
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3920
Practice Address - Country:US
Practice Address - Phone:773-307-2886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YS0200X
101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool