Provider Demographics
NPI:1265491468
Name:SHAW, REBECCA A (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:SHAW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-6324
Mailing Address - Country:US
Mailing Address - Phone:217-525-1064
Mailing Address - Fax:217-525-1651
Practice Address - Street 1:901 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-3748
Practice Address - Country:US
Practice Address - Phone:217-523-2217
Practice Address - Fax:217-788-4147
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILS49674Medicare UPIN
IL415530Medicare ID - Type Unspecified