Provider Demographics
NPI:1053689430
Name:SHAW, AMANDA J (RN, BSN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:SHAW
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 SHARON ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-5915
Mailing Address - Country:US
Mailing Address - Phone:339-223-5850
Mailing Address - Fax:
Practice Address - Street 1:52 SHARON ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5915
Practice Address - Country:US
Practice Address - Phone:339-223-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health