Healthcare Provider Details

I. General information

NPI: 1174368575
Provider Name (Legal Business Name): MS. SHAHERA KHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 06/27/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MICHIGAN AVE SUITE 1400
CHICAGO IL
60601
US

IV. Provider business mailing address

1805 CONCORD DR
GLENDALE HEIGHTS IL
60139
US

V. Phone/Fax

Practice location:
  • Phone: 312-815-9660
  • Fax:
Mailing address:
  • Phone: 630-597-6148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: