Provider Demographics
NPI:1619204088
Name:SHIBATA, BAILEY
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:SHIBATA
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 1:259 E ERIE ST STE 1900
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3246
Mailing Address - Country:US
Mailing Address - Phone:312-695-7950
Mailing Address - Fax:312-695-5747
Practice Address - Street 1:259 E ERIE ST STE 1900
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3246
Practice Address - Country:US
Practice Address - Phone:312-695-7950
Practice Address - Fax:312-695-5747
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149017373104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker