Provider Demographics
NPI:1164686135
Name:SHAW, DAVID J (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:SHAW
Suffix:
Gender:M
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6332
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33508-6005
Mailing Address - Country:US
Mailing Address - Phone:813-571-8010
Mailing Address - Fax:813-571-8010
Practice Address - Street 1:3817 CLOVERHILL CT
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7937
Practice Address - Country:US
Practice Address - Phone:813-571-8010
Practice Address - Fax:813-571-8010
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
FL1-03-1429103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist