Healthcare Provider Details

I. General information

NPI: 1053246199
Provider Name (Legal Business Name): SHANNEL CRUMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1094
MATTESON IL
60443-4094
US

IV. Provider business mailing address

PO BOX 1094
MATTESON IL
60443-4094
US

V. Phone/Fax

Practice location:
  • Phone: 773-749-9233
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150117960
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number150117960
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: