Provider Demographics
NPI:1881660611
Name:SHADE ZELDOW, YVONNE (PHD)
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:
Last Name:SHADE ZELDOW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 N WINCHESTER AVE
Mailing Address - Street 2:3RD FL
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640
Mailing Address - Country:US
Mailing Address - Phone:773-250-0500
Mailing Address - Fax:773-250-0497
Practice Address - Street 1:4501 N WINCHESTER AVE
Practice Address - Street 2:2ND FL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640
Practice Address - Country:US
Practice Address - Phone:773-250-0500
Practice Address - Fax:773-250-0497
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071002598103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071002598Medicaid
IL071002598Medicaid
ILK27685Medicare PIN
S49786Medicare UPIN