Provider Demographics
NPI:1790846368
Name:SHAW, MARCIA (MSW)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N LONGWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4134
Mailing Address - Country:US
Mailing Address - Phone:815-962-5585
Mailing Address - Fax:815-962-8945
Practice Address - Street 1:210 N LONGWOOD ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-4134
Practice Address - Country:US
Practice Address - Phone:815-962-5585
Practice Address - Fax:815-962-8945
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
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
ILL60932Medicare ID - Type Unspecified