Healthcare Provider Details

I. General information

NPI: 1558039586
Provider Name (Legal Business Name): SARAH SHIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2021
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 E BOUGHTON RD STE 265
BOLINGBROOK IL
60440-2396
US

IV. Provider business mailing address

550 E BOUGHTON RD STE 265
BOLINGBROOK IL
60440-2396
US

V. Phone/Fax

Practice location:
  • Phone: 331-318-8181
  • Fax:
Mailing address:
  • Phone: 331-318-8181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.017277
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: