Provider Demographics
NPI:1356474928
Name:MAIDES-KEANE, SHIRLEY ALLEN (PHD)
Entity type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:ALLEN
Last Name:MAIDES-KEANE
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 1:2625 BUTTERFIELD RD
Mailing Address - Street 2:SUITE 138 SOUTH
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1234
Mailing Address - Country:US
Mailing Address - Phone:630-990-1919
Mailing Address - Fax:630-990-3151
Practice Address - Street 1:2625 BUTTERFIELD RD
Practice Address - Street 2:SUITE 138 SOUTH
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1234
Practice Address - Country:US
Practice Address - Phone:630-990-1919
Practice Address - Fax:630-990-3151
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0002272088OtherBLUE SHIELD PROVIDER #
IL931270Medicare ID - Type Unspecified