Healthcare Provider Details

I. General information

NPI: 1235484064
Provider Name (Legal Business Name): SHAWANDA GAINES MS, CCC-SLP/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. SHAWANDA GAINES JONES

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8052 S. GREEN STREET
CHICAGO IL
60620-2545
US

IV. Provider business mailing address

42 W MADISON ST
CHICAGO IL
60602-4309
US

V. Phone/Fax

Practice location:
  • Phone: 708-507-5511
  • Fax: 708-757-7145
Mailing address:
  • Phone: 773-553-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12085491
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: