Provider Demographics
NPI:1225698954
Name:SHAW, DIANE ELLEN (CADAC LL)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:ELLEN
Last Name:SHAW
Suffix:
Gender:F
Credentials:CADAC LL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17261 GOTHARD ST SPC 9
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-5454
Mailing Address - Country:US
Mailing Address - Phone:714-604-5281
Mailing Address - Fax:714-547-2109
Practice Address - Street 1:1950 E 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-6852
Practice Address - Country:US
Practice Address - Phone:714-547-4300
Practice Address - Fax:714-547-2109
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA014670315101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty