Provider Demographics
NPI:1811130792
Name:SHANE, DAVID W (LCSW (ILLINOIS))
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:W
Last Name:SHANE
Suffix:
Gender:M
Credentials:LCSW (ILLINOIS)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 S FREMONT ST
Mailing Address - Street 2:ORCHARD CORNERS 150-160
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-1508
Mailing Address - Country:US
Mailing Address - Phone:712-246-0092
Mailing Address - Fax:
Practice Address - Street 1:512 S FREMONT ST
Practice Address - Street 2:ORCHARD CORNERS 150-160
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601-1508
Practice Address - Country:US
Practice Address - Phone:712-246-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0028711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical