Healthcare Provider Details

I. General information

NPI: 1467023150
Provider Name (Legal Business Name): EAR TO EAR BEHAVIORAL HEALTH SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2021
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W LAKE ST
CHICAGO IL
60606-0239
US

IV. Provider business mailing address

924 N AUSTIN BLVD
OAK PARK IL
60302-1713
US

V. Phone/Fax

Practice location:
  • Phone: 773-232-2222
  • Fax: 773-232-1893
Mailing address:
  • Phone: 708-208-4651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. COREY WENDELL SHUMATE
Title or Position: NURSE PRACTITIONER
Credential: PMHNP-BC
Phone: 708-208-4651