Healthcare Provider Details

I. General information

NPI: 1255203949
Provider Name (Legal Business Name): DHARA SHAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2025
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3665 N BROADWAY ST
CHICAGO IL
60613-4567
US

IV. Provider business mailing address

3665 N BROADWAY ST
CHICAGO IL
60613-4567
US

V. Phone/Fax

Practice location:
  • Phone: 773-496-4433
  • Fax: 773-496-4430
Mailing address:
  • Phone: 773-496-4433
  • Fax: 773-496-4430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: