Active NPI
Shaniqua Blackman
- Mental Health Counselor
- Lake Villa, IL
National Provider Identifier
1063389336
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- 180.017610
- Practice address
- 600 W Grand Ave
Lake Villa, IL 60046-8034 - Phone
- (847) 245-6276
- NPI assigned
- Oct 21, 2025
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | 180.017610 | IL | Primary |
Addresses
Primary practice location
600 W Grand Ave
Lake Villa, IL 60046-8034
Mailing address
11141 S Ashland Ave
Chicago, IL 60643-3513
Phone (312) 230-8104
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 180.017610 | IL | MD | Mental Health Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1761004800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1761264000000",
"number": "1063389336",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "11141 S ASHLAND AVE",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606433513",
"telephone_number": "312-230-8104"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "600 W GRAND AVE",
"city": "LAKE VILLA",
"state": "IL",
"postal_code": "600468034",
"telephone_number": "847-245-6276"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BLACKMAN",
"first_name": "SHANIQUA",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2025-10-21",
"last_updated": "2025-10-24",
"certification_date": "2025-10-21",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Counselor, Mental Health",
"state": "IL",
"license": "180.017610",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Lake Villa, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 24, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.