Provider Demographics
NPI:1639581978
Name:PRENDERGAST, SHELLEY (LCPC)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 E MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2287
Mailing Address - Country:US
Mailing Address - Phone:630-377-6613
Mailing Address - Fax:630-377-6225
Practice Address - Street 1:110 E COUNTRYSIDE PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-1813
Practice Address - Country:US
Practice Address - Phone:630-553-1600
Practice Address - Fax:630-553-7993
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178008965101YP2500X
IL180009302101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional