Provider Demographics
NPI:1801403001
Name:SEYMORE, SHANEQUIA
Entity Type:Individual
Prefix:
First Name:SHANEQUIA
Middle Name:
Last Name:SEYMORE
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 1:3431 ATTICA RD
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1307
Mailing Address - Country:US
Mailing Address - Phone:872-243-9945
Mailing Address - Fax:
Practice Address - Street 1:3431 ATTICA RD
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1307
Practice Address - Country:US
Practice Address - Phone:872-243-9945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0226461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical