Provider Demographics
NPI:1609616275
Name:MILLER, SHANNON (LSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18640 W IL ROUTE 120
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-9733
Mailing Address - Country:US
Mailing Address - Phone:847-548-6000
Mailing Address - Fax:847-548-6040
Practice Address - Street 1:18640 W IL ROUTE 120
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-9733
Practice Address - Country:US
Practice Address - Phone:847-548-6000
Practice Address - Fax:847-548-6040
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IL1490274211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker