Provider Demographics
NPI:1811641335
Name:SOUMAR, SHELBY (MSBP - BCBA)
Entity type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:
Last Name:SOUMAR
Suffix:
Gender:F
Credentials:MSBP - BCBA
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:
Other - Last Name:SUTTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3 ELM CREEK DR APT 103
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5288
Mailing Address - Country:US
Mailing Address - Phone:630-701-5696
Mailing Address - Fax:
Practice Address - Street 1:625 SLAWIN CT
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-2183
Practice Address - Country:US
Practice Address - Phone:715-584-7789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-21-57189103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty