Provider Demographics
NPI:1710098611
Name:CARDWELL, SHENANDOAH (MA, NCC, LCPC)
Entity Type:Individual
Prefix:MS
First Name:SHENANDOAH
Middle Name:
Last Name:CARDWELL
Suffix:
Gender:F
Credentials:MA, NCC, LCPC
Other - Prefix:MRS
Other - First Name:SHENANDOAH
Other - Middle Name:CARDWELL
Other - Last Name:CONSTANTINO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:34930 N US HIGHWAY 45
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-7537
Mailing Address - Country:US
Mailing Address - Phone:847-543-7755
Mailing Address - Fax:847-543-7759
Practice Address - Street 1:34930 N US HIGHWAY 45
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-7537
Practice Address - Country:US
Practice Address - Phone:847-543-7755
Practice Address - Fax:847-543-7759
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC CERT # 22818101Y00000X
WI2906-125101YP2500X
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL169887OtherMHN PROVIDER #