Provider Demographics
NPI:1063389336
Name:BLACKMAN, SHANIQUA
Entity type:Individual
Prefix:
First Name:SHANIQUA
Middle Name:
Last Name:BLACKMAN
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 1:11141 S ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-3513
Mailing Address - Country:US
Mailing Address - Phone:312-230-8104
Mailing Address - Fax:
Practice Address - Street 1:600 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-8034
Practice Address - Country:US
Practice Address - Phone:847-245-6276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-21
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.017610101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty