Provider Demographics
NPI:1154489276
Name:SHAW, BETHANY ANN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:ANN
Last Name:SHAW
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MRS
Other - First Name:BETHANY
Other - Middle Name:ANN
Other - Last Name:WALUZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:167 S STATE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-2265
Mailing Address - Country:US
Mailing Address - Phone:614-794-3138
Mailing Address - Fax:614-794-3175
Practice Address - Street 1:167 S STATE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-2265
Practice Address - Country:US
Practice Address - Phone:614-794-3138
Practice Address - Fax:614-794-3175
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5212103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical