Provider Demographics
NPI:1245363860
Name:SHOLL, STARLA RAE (LCSW)
Entity type:Individual
Prefix:MS
First Name:STARLA
Middle Name:RAE
Last Name:SHOLL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5349 N WINTHROP AVE
Mailing Address - Street 2:#2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2309
Mailing Address - Country:US
Mailing Address - Phone:773-878-5809
Mailing Address - Fax:773-878-5809
Practice Address - Street 1:5349 N WINTHROP AVE
Practice Address - Street 2:#2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2309
Practice Address - Country:US
Practice Address - Phone:773-878-5809
Practice Address - Fax:773-878-5809
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1627237OtherBLUE CROSS & BLUE SHIELD