Provider Demographics
NPI:1992743074
Name:SHAW, OLETA L (LICSW)
Entity type:Individual
Prefix:
First Name:OLETA
Middle Name:L
Last Name:SHAW
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 RIVERDALE ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-1024
Mailing Address - Country:US
Mailing Address - Phone:413-827-4363
Mailing Address - Fax:413-827-4204
Practice Address - Street 1:2112 RIVERDALE ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-1024
Practice Address - Country:US
Practice Address - Phone:413-827-4363
Practice Address - Fax:413-827-4204
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1135381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical