Provider Demographics
NPI:1669352225
Name:DENNIS SHAVE, KELSEY LYNN
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYNN
Last Name:DENNIS SHAVE
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 1:500 W MONROE ST FL 18
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-3759
Mailing Address - Country:US
Mailing Address - Phone:312-663-1130
Mailing Address - Fax:312-663-0504
Practice Address - Street 1:404 N HERSHEY RD STE C
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3560
Practice Address - Country:US
Practice Address - Phone:877-381-6538
Practice Address - Fax:312-663-0504
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-04
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008381101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty