Provider Demographics
NPI:1831770171
Name:SHAVER, ANGELA ROSE (CDCA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:ROSE
Last Name:SHAVER
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:MR
Other - First Name:ANGELA
Other - Middle Name:ROSE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14761 ST RT 93 UNIT 4
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640
Mailing Address - Country:US
Mailing Address - Phone:740-208-6923
Mailing Address - Fax:
Practice Address - Street 1:14761 STATE ROUTE 93 UNIT 4
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9820
Practice Address - Country:US
Practice Address - Phone:740-577-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH176433101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH176433Medicaid