Provider Demographics
NPI:1235577545
Name:SHAW, DIETRICH J
Entity Type:Individual
Prefix:
First Name:DIETRICH
Middle Name:J
Last Name:SHAW
Suffix:
Gender:M
Credentials:
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 284
Mailing Address - Street 2:
Mailing Address - City:YAMHILL
Mailing Address - State:OR
Mailing Address - Zip Code:97148-0284
Mailing Address - Country:US
Mailing Address - Phone:503-560-8881
Mailing Address - Fax:
Practice Address - Street 1:105 W 2ND ST
Practice Address - Street 2:#U
Practice Address - City:YAMHILL
Practice Address - State:OR
Practice Address - Zip Code:97148-2204
Practice Address - Country:US
Practice Address - Phone:503-560-8881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-08
Last Update Date:2013-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health