Provider Demographics
NPI:1184378911
Name:GENDELMAN, SHIMON ARIEL (LCPC)
Entity type:Individual
Prefix:
First Name:SHIMON
Middle Name:ARIEL
Last Name:GENDELMAN
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6550 N FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-4411
Mailing Address - Country:US
Mailing Address - Phone:773-899-6783
Mailing Address - Fax:
Practice Address - Street 1:6550 N FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-4411
Practice Address - Country:US
Practice Address - Phone:773-899-6783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-10
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180014166101YM0800X
IL180.014166101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health