Provider Demographics
NPI:1689980542
Name:SHAW, WUNDERLY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:WUNDERLY
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 BUTLER ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BERWICK
Mailing Address - State:ME
Mailing Address - Zip Code:03908-1315
Mailing Address - Country:US
Mailing Address - Phone:207-384-2705
Mailing Address - Fax:
Practice Address - Street 1:49 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BERWICK
Practice Address - State:ME
Practice Address - Zip Code:03908-1503
Practice Address - Country:US
Practice Address - Phone:207-384-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-29
Last Update Date:2010-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist