Provider Demographics
NPI:1700866506
Name:SHAW, VERNON ALLEN (CCC-A)
Entity Type:Individual
Prefix:
First Name:VERNON
Middle Name:ALLEN
Last Name:SHAW
Suffix:
Gender:M
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 E 86TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6267
Mailing Address - Country:US
Mailing Address - Phone:219-738-2528
Mailing Address - Fax:219-738-2529
Practice Address - Street 1:99 E 86TH AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6381
Practice Address - Country:US
Practice Address - Phone:219-738-2617
Practice Address - Fax:219-738-2145
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23001343A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000288063OtherANTHEM
IN200098570Medicaid
IN200098570Medicaid
IN640004819Medicare PIN