Provider Demographics
NPI:1881118354
Name:SHAW, MATTHEW (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1162 ST. GEORGE'S AVENUE PMB #278
Mailing Address - Street 2:PMB #278
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001
Mailing Address - Country:US
Mailing Address - Phone:732-540-5577
Mailing Address - Fax:
Practice Address - Street 1:35 CLAYTON CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095-1934
Practice Address - Country:US
Practice Address - Phone:732-540-5577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-27
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00819000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty