Provider Demographics
NPI:1851138325
Name:FUKARI PSYCH, PLLC
Entity type:Organization
Organization Name:FUKARI PSYCH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:815-479-4140
Mailing Address - Street 1:3204 BISCAYNE RD
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8321
Mailing Address - Country:US
Mailing Address - Phone:815-236-8836
Mailing Address - Fax:
Practice Address - Street 1:10 N LAKE ST STE 109
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-3636
Practice Address - Country:US
Practice Address - Phone:815-479-4140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty