Healthcare Provider Details

I. General information

NPI: 1649007980
Provider Name (Legal Business Name): SHANNON LEA EXLEY M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 GREEN BAY RD
NORTH CHICAGO IL
60064-3048
US

IV. Provider business mailing address

440 GREEN BAY RD UNIT 308
HIGHWOOD IL
60040-1328
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-1900
  • Fax:
Mailing address:
  • Phone: 760-917-3681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810009147
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: