Provider Demographics
NPI:1912983651
Name:SONG, SHARON (PHD)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:SONG
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 1:909 E PALATINE RD
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074-5551
Mailing Address - Country:US
Mailing Address - Phone:847-776-1400
Mailing Address - Fax:847-776-1424
Practice Address - Street 1:909 E PALATINE RD
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074-5551
Practice Address - Country:US
Practice Address - Phone:847-776-1400
Practice Address - Fax:847-776-1424
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006607103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01618781OtherBC/BS
ILP00141499OtherMEDICARE RAILROAD
ILP00141499OtherMEDICARE RAILROAD