=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588174460
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHIRLYN GARRETT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2017
-----------------------------------------------------
Last Update Date | 10/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18631 LARAMIE RD
-----------------------------------------------------
City | COUNTRY CLUB HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60478-4412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-320-9592
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18631 LARAMIE RD
-----------------------------------------------------
City | COUNTRY CLUB HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60478-4412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-320-9592
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180-0004034
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------