Healthcare Provider Details

I. General information

NPI: 1013320522
Provider Name (Legal Business Name): MISS ANNIE SHEA NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 06/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 N PULASKI RD BUILDING C, 2ND FLOOR
CHICAGO IL
60646-6007
US

IV. Provider business mailing address

5801 N PULASKI RD BUILDING C, 2ND FLOOR
CHICAGO IL
60646-6007
US

V. Phone/Fax

Practice location:
  • Phone: 312-744-1906
  • Fax: 312-744-5568
Mailing address:
  • Phone: 312-744-1906
  • Fax: 312-744-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: