MEDICARE: SHACOBY S. TINES

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1861993776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHACOBY S. TINES

Provider Business Mailing Address
First Line	:	10616 S NORMAL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-2432
Country	:	US
Telephone Number	:	708-819-6100
Fax Number	:

Provider Business Practice Location Address
First Line	:	10616 S NORMAL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-2432
Country	:	US
Telephone Number	:	708-819-6100
Fax Number	:

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

Provider Enumeration Date	:	02/26/2018
Last Update Date	:	06/26/2020

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Directions to “ SHACOBY S. TINES ” Practice Location

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