Provider Demographics
NPI:1023272903
Name:SHAH, FALGUNI A (MED, LCPC)
Entity type:Individual
Prefix:
First Name:FALGUNI
Middle Name:A
Last Name:SHAH
Suffix:
Gender:F
Credentials:MED, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4753 N BROADWAY ST STE 700
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-4995
Mailing Address - Country:US
Mailing Address - Phone:773-293-8461
Mailing Address - Fax:773-728-4751
Practice Address - Street 1:4753 N BROADWAY ST STE 700
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4995
Practice Address - Country:US
Practice Address - Phone:773-293-8461
Practice Address - Fax:773-728-4751
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006396101YP2500X
IL180006396261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1548382690Medicaid