Healthcare Provider Details

I. General information

NPI: 1538023486
Provider Name (Legal Business Name): MICHAEL JAMES SHANAHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N RIVER RD
DES PLAINES IL
60016-1214
US

IV. Provider business mailing address

4800 S CHICAGO BEACH DR APT 1609N
CHICAGO IL
60615-2059
US

V. Phone/Fax

Practice location:
  • Phone: 847-294-1999
  • Fax:
Mailing address:
  • Phone: 312-615-5573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180.016820
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: