Provider Demographics
NPI:1780382614
Name:ANDERSON, SHANA MARIE
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13718 CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ROBBINS
Mailing Address - State:IL
Mailing Address - Zip Code:60472-1918
Mailing Address - Country:US
Mailing Address - Phone:708-738-3757
Mailing Address - Fax:
Practice Address - Street 1:2200 HUNTINGTON DR N
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-4419
Practice Address - Country:US
Practice Address - Phone:630-229-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health