Provider Demographics
NPI:1194118802
Name:KACOS-SHIU, FAYA (MSW)
Entity type:Individual
Prefix:
First Name:FAYA
Middle Name:
Last Name:KACOS-SHIU
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E. COOK AVE.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2060
Mailing Address - Country:US
Mailing Address - Phone:847-816-6441
Mailing Address - Fax:847-816-6355
Practice Address - Street 1:150 E. COOK AVE.
Practice Address - Street 2:SUITE 100
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2060
Practice Address - Country:US
Practice Address - Phone:847-816-6441
Practice Address - Fax:847-816-6355
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL149.019790101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL366006600Medicaid