Provider Demographics
NPI:1992549208
Name:SACK, SHELBY
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:SACK
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 1:3822 N LINCOLN AVE # 2N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3520
Mailing Address - Country:US
Mailing Address - Phone:816-309-0413
Mailing Address - Fax:
Practice Address - Street 1:2833 N CLYBOURN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-8470
Practice Address - Country:US
Practice Address - Phone:847-604-0027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.016067225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics