Provider Demographics
NPI:1083996870
Name:SHAW, TONYA LYN (LSW)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:LYN
Last Name:SHAW
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E. GRAND AVE.
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046
Mailing Address - Country:US
Mailing Address - Phone:847-377-8386
Mailing Address - Fax:
Practice Address - Street 1:121 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-7829
Practice Address - Country:US
Practice Address - Phone:847-377-8386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.0110401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical