Provider Demographics
NPI:1477998102
Name:SHAW, SHEENA SHEREE (BS)
Entity Type:Individual
Prefix:
First Name:SHEENA
Middle Name:SHEREE
Last Name:SHAW
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5127 W GLADYS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-4845
Mailing Address - Country:US
Mailing Address - Phone:773-744-7031
Mailing Address - Fax:
Practice Address - Street 1:5127 W GLADYS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-4845
Practice Address - Country:US
Practice Address - Phone:773-744-7031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILS00079788953222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist