Healthcare Provider Details

I. General information

NPI: 1790400497
Provider Name (Legal Business Name): ALICIA SHAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 N MORGAN ST
SHELBYVILLE IL
62565-1672
US

IV. Provider business mailing address

249 N MORGAN ST
SHELBYVILLE IL
62565-1672
US

V. Phone/Fax

Practice location:
  • Phone: 217-774-1400
  • Fax:
Mailing address:
  • Phone: 217-774-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37020
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: