MEDICARE: RUTH SHANNON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	178016335	IL

General Provider Information

NPI Number	:	1164196994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUTH SHANNON

Provider Business Mailing Address
First Line	:	7616 S MERRILL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-4133
Country	:	US
Telephone Number	:	312-459-1372
Fax Number	:	866-808-3495

Provider Business Practice Location Address
First Line	:	7616 S MERRILL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-4133
Country	:	US
Telephone Number	:	312-459-1372
Fax Number	:	866-808-3495

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2021
Last Update Date	:	08/04/2021

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