Provider Demographics
NPI:1063838365
Name:SHAW, MAKEDA
Entity Type:Individual
Prefix:
First Name:MAKEDA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 LEFFERTS AVE
Mailing Address - Street 2:APT D9
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-4347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:345 LEFFERTS AVE
Practice Address - Street 2:APT D9
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-4347
Practice Address - Country:US
Practice Address - Phone:917-723-1899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool