Provider Demographics
NPI:1093750192
Name:SHAW, SANDRA C (LCSW/ACSW)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:C
Last Name:SHAW
Suffix:
Gender:F
Credentials:LCSW/ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-1701
Mailing Address - Country:US
Mailing Address - Phone:916-967-0778
Mailing Address - Fax:916-726-5195
Practice Address - Street 1:7777 GREENBACK LN
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-5800
Practice Address - Country:US
Practice Address - Phone:916-967-0778
Practice Address - Fax:916-726-5195
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS# 108811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29683ZMedicare ID - Type Unspecified