Provider Demographics
NPI:1962456566
Name:SHAHTAJI, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SHAHTAJI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:SPORTOLARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 E OGDEN AVE
Mailing Address - Street 2:STE 126
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3633
Mailing Address - Country:US
Mailing Address - Phone:630-325-6133
Mailing Address - Fax:630-325-4751
Practice Address - Street 1:4928 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2504
Practice Address - Country:US
Practice Address - Phone:708-424-0143
Practice Address - Fax:708-425-8833
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147000805231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL82789Medicare ID - Type UnspecifiedPROVIDER ID NUMBER