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General NPI Number Information
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NPI Number | 1518761832
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Entity Type | Individual
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Provider Name | LARA JEAN SHAW LSW
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Gender | Female
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Dates
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Enumeration Date | 04/03/2025
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Last Update Date | 04/03/2025
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Provider Practice Location Address
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Address Line | 1200 LOCUST ST
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City | ELDORADO
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State | IL
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Zip | 62930-1723
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Country | US
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Telephone | 618-252-9036
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Fax |
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Provider Business Mailing Address
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Address Line | 2222 NORTH ST
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City | HARRISBURG
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State | IL
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Zip | 62946-3421
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Country | US
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Telephone | 618-499-4918
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 150.113062
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License Number State | IL
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