Provider Demographics
NPI:1679134332
Name:SHANMUGAVELAYUTHAM, SHOBANA U
Entity Type:Individual
Prefix:
First Name:SHOBANA
Middle Name:U
Last Name:SHANMUGAVELAYUTHAM
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 1:2301 BEAU MONDE TER APT 106
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1528
Mailing Address - Country:US
Mailing Address - Phone:331-551-2447
Mailing Address - Fax:
Practice Address - Street 1:600 E DIEHL RD STE 110
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-4896
Practice Address - Country:US
Practice Address - Phone:630-428-7890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012070101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health