Provider Demographics
NPI:1255086096
Name:SHUCK, COREY (LSW)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:SHUCK
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 W GRAND AVE APT 3501
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4558
Mailing Address - Country:US
Mailing Address - Phone:651-508-2365
Mailing Address - Fax:
Practice Address - Street 1:2400 N ASHLAND AVE # 174
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2021
Practice Address - Country:US
Practice Address - Phone:773-270-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.105528104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker