Provider Demographics
NPI:1083274328
Name:SHAW, KIMBERLY SCOTT (MFT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SCOTT
Last Name:SHAW
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 SYCAMORE AVE UNIT 5632
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-6027
Mailing Address - Country:US
Mailing Address - Phone:510-495-4217
Mailing Address - Fax:
Practice Address - Street 1:140 MAYHEW WAY STE 300
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-4398
Practice Address - Country:US
Practice Address - Phone:510-495-4217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46135106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist