Healthcare Provider Details

I. General information

NPI: 1588050611
Provider Name (Legal Business Name): SHAWNTRELL MOORE MA LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W ONTARIO ST STE 150
CHICAGO IL
60654-6750
US

IV. Provider business mailing address

401 W ONTARIO ST STE 150
CHICAGO IL
60654-6750
US

V. Phone/Fax

Practice location:
  • Phone: 217-816-1154
  • Fax:
Mailing address:
  • Phone: 217-816-1154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.014761
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: