Provider Demographics
NPI:1366932956
Name:WU, SHENGTIAN
Entity type:Individual
Prefix:
First Name:SHENGTIAN
Middle Name:
Last Name:WU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 BEACON HILL CT
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5410
Mailing Address - Country:US
Mailing Address - Phone:401-588-2726
Mailing Address - Fax:401-588-2726
Practice Address - Street 1:1306 BEACON HILL CT
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-5410
Practice Address - Country:US
Practice Address - Phone:401-588-2726
Practice Address - Fax:401-588-2726
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool