Provider Demographics
NPI:1629102082
Name:NELSON, SHANNON CHRISTINE (LSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:CHRISTINE
Last Name:NELSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 W FOSTER AVE
Mailing Address - Street 2:433
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2147
Mailing Address - Country:US
Mailing Address - Phone:847-723-5824
Mailing Address - Fax:
Practice Address - Street 1:1775 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1143
Practice Address - Country:US
Practice Address - Phone:847-723-5824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical