Provider Demographics
NPI:1063836609
Name:SHAW, DANIEL ANTWAIN (MAE)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ANTWAIN
Last Name:SHAW
Suffix:
Gender:M
Credentials:MAE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PAWNEE COUNTY 907 W. CADDO ST.
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OK
Mailing Address - Zip Code:74020-4201
Mailing Address - Country:US
Mailing Address - Phone:918-308-5511
Mailing Address - Fax:918-205-2701
Practice Address - Street 1:907 W CADDO ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020-4201
Practice Address - Country:US
Practice Address - Phone:918-308-5511
Practice Address - Fax:918-205-2701
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator