Provider Demographics
NPI:1164661757
Name:SHAW, TERRI A (PHD)
Entity Type:Individual
Prefix:MRS
First Name:TERRI
Middle Name:A
Last Name:SHAW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 DARIEN DR.
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815
Mailing Address - Country:US
Mailing Address - Phone:260-385-2291
Mailing Address - Fax:
Practice Address - Street 1:1616 DARIEN DR.
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815
Practice Address - Country:US
Practice Address - Phone:260-385-2291
Practice Address - Fax:260-407-0094
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-05
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002331A101YM0800X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health