Provider Demographics
NPI:1942634191
Name:IBRAHIM, SHADIA (LMHC)
Entity Type:Individual
Prefix:
First Name:SHADIA
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6741 PORTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-2432
Mailing Address - Country:US
Mailing Address - Phone:219-730-7572
Mailing Address - Fax:
Practice Address - Street 1:1441 E 84TH PL
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6451
Practice Address - Country:US
Practice Address - Phone:219-794-2000
Practice Address - Fax:219-794-2010
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-23
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002451A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health