Provider Demographics
NPI:1851803209
Name:SHAW, ANGELA GREENWALD
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:GREENWALD
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 1:922 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-1430
Mailing Address - Country:US
Mailing Address - Phone:815-973-4928
Mailing Address - Fax:
Practice Address - Street 1:922 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-1430
Practice Address - Country:US
Practice Address - Phone:815-973-4928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146005644235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist