MEDICARE: SHEENA FAGOON SHUKLA

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	104100000X	Social Worker	150104225	IL

General Provider Information

NPI Number	:	1548843345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHEENA FAGOON SHUKLA

Provider Business Mailing Address
First Line	:	1901 S CALUMET AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-6044
Country	:	US
Telephone Number	:	630-740-1413
Fax Number	:

Provider Business Practice Location Address
First Line	:	1901 S CALUMET AVE UNIT 1708
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-6019
Country	:	US
Telephone Number	:	630-740-1413
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/30/2021
Last Update Date	:	04/30/2021

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