Provider Demographics
NPI:1528303161
Name:ELLISON, SHADON MICHELE (BS)
Entity type:Individual
Prefix:MS
First Name:SHADON
Middle Name:MICHELE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:BS
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4820 S KING DR
Mailing Address - Street 2:APT. 1S
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-1349
Mailing Address - Country:US
Mailing Address - Phone:312-320-2844
Mailing Address - Fax:708-529-5868
Practice Address - Street 1:4820 S KING DR
Practice Address - Street 2:APT. 1S
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-1349
Practice Address - Country:US
Practice Address - Phone:312-320-2844
Practice Address - Fax:708-529-5868
Is Sole Proprietor?:No
Enumeration Date:2012-12-08
Last Update Date:2013-03-02
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist