Provider Demographics
NPI:1659408003
Name:SUFI, SHAMIM A (MA , LCSW)
Entity Type:Individual
Prefix:
First Name:SHAMIM
Middle Name:A
Last Name:SUFI
Suffix:
Gender:F
Credentials:MA , LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 CONAN DOYLE RD
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-4106
Mailing Address - Country:US
Mailing Address - Phone:630-904-1637
Mailing Address - Fax:630-922-8509
Practice Address - Street 1:3033 W JEFFERSON ST
Practice Address - Street 2:SUITE 207
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5261
Practice Address - Country:US
Practice Address - Phone:630-935-2787
Practice Address - Fax:639-922-8509
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILSS70450102POtherEARLY INTERVENTION PROVID
ILSS70450102POtherEARLY INTERVENTION PROVID