Provider Demographics
NPI:1639373236
Name:SHAW, ROGER ALLEN (LMFT)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:ALLEN
Last Name:SHAW
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 RIGGS DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-1014
Mailing Address - Country:US
Mailing Address - Phone:217-735-2628
Mailing Address - Fax:
Practice Address - Street 1:1003 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-1429
Practice Address - Country:US
Practice Address - Phone:309-820-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist