Provider Demographics
NPI:1760053813
Name:SHAW, REGINA DONNETTE
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:DONNETTE
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 W FLORIST AVE STE 125
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-3862
Mailing Address - Country:US
Mailing Address - Phone:414-247-0801
Mailing Address - Fax:141-247-0816
Practice Address - Street 1:1720 W FLORIST AVE STE 125
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-3862
Practice Address - Country:US
Practice Address - Phone:414-247-0801
Practice Address - Fax:414-247-0816
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4981101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4981OtherLICENSE