Healthcare Provider Details

I. General information

NPI: 1669352225
Provider Name (Legal Business Name): KELSEY LYNN DENNIS SHAVE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2025
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 N HERSHEY RD STE C
BLOOMINGTON IL
61704-3560
US

IV. Provider business mailing address

500 W MONROE ST FL 18
CHICAGO IL
60661-3759
US

V. Phone/Fax

Practice location:
  • Phone: 877-381-6538
  • Fax: 312-663-0504
Mailing address:
  • Phone: 312-663-1130
  • Fax: 312-663-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180008381
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: