Basic Information
| Provider Information | |||||||||
| NPI: | 1033531991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | ANGELA | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 438 S GEORGIE AVE | ||||||||
| Address2: | |||||||||
| City: | DERBY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670371224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167890620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 635 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672033602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166607600 | ||||||||
| FaxNumber: | 3166607510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2014 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1494 | KS | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 8916 | KS | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.