Basic Information
| Provider Information | |||||||||
| NPI: | 1023272903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | FALGUNI | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.ED, LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4753 N BROADWAY ST STE 700 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606404995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732938461 | ||||||||
| FaxNumber: | 7737284751 | ||||||||
| Practice Location | |||||||||
| Address1: | 4753 N BROADWAY ST STE 700 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606404995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732938461 | ||||||||
| FaxNumber: | 7737284751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2008 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 180.006396 | IL | N | Behavioral Health & Social Service Providers | Counselor | Professional | 261QM0801X | 180006396 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1548382690 | 05 | IL | MEDICAID |