Healthcare Provider Details

I. General information

NPI: 1831026418
Provider Name (Legal Business Name): BRIDGET SHANE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E GRAND AVE
CHICAGO IL
60611-3800
US

IV. Provider business mailing address

160 E GRAND AVE STE 500
CHICAGO IL
60611-3800
US

V. Phone/Fax

Practice location:
  • Phone: 847-686-0090
  • Fax: 847-503-0813
Mailing address:
  • Phone: 847-686-0090
  • Fax: 847-503-0813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.022642
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: