MEDICARE: DR. SHAWNA BROUGH PSYD

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	103TC0700X	Clinical Psychologist	071.011116	IL

General Provider Information

NPI Number	:	1811547342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHAWNA BROUGH PSYD

Provider Business Mailing Address
First Line	:	5215 N RAVENSWOOD AVE STE 212
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1670
Country	:	US
Telephone Number	:	872-205-9931
Fax Number	:

Provider Business Practice Location Address
First Line	:	5215 N RAVENSWOOD AVE STE 212
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1670
Country	:	US
Telephone Number	:	872-205-9931
Fax Number	:

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

Provider Enumeration Date	:	09/17/2019
Last Update Date	:	01/16/2026

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