Healthcare Provider Details

I. General information

NPI: 1639062508
Provider Name (Legal Business Name): LEON SHAW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2025
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 PARK ST STE 200
NAPERVILLE IL
60563-8404
US

IV. Provider business mailing address

1755 PARK ST STE 200
NAPERVILLE IL
60563-8404
US

V. Phone/Fax

Practice location:
  • Phone: 815-260-6051
  • Fax:
Mailing address:
  • Phone: 815-260-6051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: