Healthcare Provider Details

I. General information

NPI: 1194152769
Provider Name (Legal Business Name): ANDREA LYNN SHRYOCK L.C.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 WASHINGTON SQ
WASHINGTON IL
61571-2657
US

IV. Provider business mailing address

200 HAWKEYE WAY
SPRINGFIELD IL
62707-5722
US

V. Phone/Fax

Practice location:
  • Phone: 800-773-1682
  • Fax:
Mailing address:
  • Phone: 217-415-2140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180-006626
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178-003130
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number228311
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: