Provider Demographics
NPI:1275198194
Name:SHAW, DIEDRE (LICSW)
Entity Type:Individual
Prefix:
First Name:DIEDRE
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 S 84TH ST STE L101
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2601
Mailing Address - Country:US
Mailing Address - Phone:402-326-9168
Mailing Address - Fax:402-261-6319
Practice Address - Street 1:245 S 84TH ST STE L101
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2601
Practice Address - Country:US
Practice Address - Phone:402-326-9168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE73601041C0700X
NE3052101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical