Healthcare Provider Details

I. General information

NPI: 1003235722
Provider Name (Legal Business Name): PUJA SHAH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 ROHLWING RD
ELK GROVE VLG IL
60007-3217
US

IV. Provider business mailing address

2049 IVY RIDGE DR
HOFFMAN ESTATES IL
60192-4153
US

V. Phone/Fax

Practice location:
  • Phone: 847-524-8800
  • Fax:
Mailing address:
  • Phone: 630-400-1585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.011009
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: