Provider Demographics
NPI:1619785128
Name:HARE, SHANTEACE
Entity type:Individual
Prefix:
First Name:SHANTEACE
Middle Name:
Last Name:HARE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11550 S WATKINS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-4916
Mailing Address - Country:US
Mailing Address - Phone:773-914-1765
Mailing Address - Fax:
Practice Address - Street 1:5540 W 111TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5574
Practice Address - Country:US
Practice Address - Phone:708-634-0821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician