Provider Demographics
NPI:1861993776
Name:TINES, SHACOBY S
Entity type:Individual
Prefix:
First Name:SHACOBY
Middle Name:S
Last Name:TINES
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 1:10616 S NORMAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-2432
Mailing Address - Country:US
Mailing Address - Phone:708-819-6100
Mailing Address - Fax:
Practice Address - Street 1:10616 S NORMAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-2432
Practice Address - Country:US
Practice Address - Phone:708-819-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty