Provider Demographics
NPI:1477372761
Name:SHAW, ANGIE JANE (CSW)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:JANE
Last Name:SHAW
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 N 1950 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-3100
Mailing Address - Country:US
Mailing Address - Phone:801-462-5114
Mailing Address - Fax:
Practice Address - Street 1:195 N 1950 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-3100
Practice Address - Country:US
Practice Address - Phone:801-462-5114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7434446-3502104100000X, 261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No104100000XBehavioral Health & Social Service ProvidersSocial Worker