Provider Demographics
NPI:1992420525
Name:YOUNG, SHAH'TAVIA (LSW)
Entity type:Individual
Prefix:
First Name:SHAH'TAVIA
Middle Name:
Last Name:YOUNG
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 1:405 W SUPERIOR ST STE 427
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-8501
Mailing Address - Country:US
Mailing Address - Phone:773-897-3197
Mailing Address - Fax:
Practice Address - Street 1:405 W SUPERIOR ST STE 427
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-8501
Practice Address - Country:US
Practice Address - Phone:773-897-3197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.106617104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker