MEDICARE: COLLECTIVE INSIGHT PLLC

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1215656657
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLECTIVE INSIGHT PLLC

Provider Business Mailing Address
First Line	:	812 W WAVELAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-4820
Country	:	US
Telephone Number	:	708-560-6653
Fax Number	:

Provider Business Practice Location Address
First Line	:	812 W WAVELAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-4820
Country	:	US
Telephone Number	:	708-560-6653
Fax Number	:

Authorized Official
Title or Position	:	OWNER / CLINICAL PSYCHOLOGIST
Name	:	DR. SHELBY MAILHO
Credential	:	PSY.D.
Telephone Number	:	773-234-2881

Provider Enumeration Date	:	08/26/2022
Last Update Date	:	10/26/2022

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