MEDICARE: SHAMARI MENTORING COMPANY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	180007662	IL
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1205344173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHAMARI MENTORING COMPANY

Provider Business Mailing Address
First Line	:	5401 THELEN AVE
Second Line	:
City	:	MCHENRY
State	:	IL
Zip	:	60050-7641
Country	:	US
Telephone Number	:	847-323-1199
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 W ROLLINS RD
Second Line	:
City	:	ROULD LAKE HEIGHTS
State	:	IL
Zip	:	60073
Country	:	US
Telephone Number	:	224-308-4108
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER AND DIRECTOR
Name	:	MR. OLABODE OLUWOLE OBAFEMI
Credential	:
Telephone Number	:	224-308-4108

Provider Enumeration Date	:	01/13/2018
Last Update Date	:	06/16/2018

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