Provider Demographics
NPI:1083437677
Name:VANCE, SHANEIL ELIZABETH
Entity type:Individual
Prefix:
First Name:SHANEIL
Middle Name:ELIZABETH
Last Name:VANCE
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 1:1750 BROADWAY ST TRLR 3022
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2780
Mailing Address - Country:US
Mailing Address - Phone:773-943-0551
Mailing Address - Fax:
Practice Address - Street 1:1750 BROADWAY ST TRLR 3022
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2780
Practice Address - Country:US
Practice Address - Phone:773-943-0551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180016098101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional