Provider Demographics
NPI:1659327229
Name:SHACK, ANDREW VINCENT (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:VINCENT
Last Name:SHACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1103 WESTGATE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1088
Mailing Address - Country:US
Mailing Address - Phone:708-386-8112
Mailing Address - Fax:708-383-4298
Practice Address - Street 1:1103 WESTGATE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1088
Practice Address - Country:US
Practice Address - Phone:708-386-8112
Practice Address - Fax:708-383-4298
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL071-006231103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL938570Medicare UPIN