Provider Demographics
NPI:1326210659
Name:SHAW, MICHELE LINDEN (EDD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:LINDEN
Last Name:SHAW
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:DR
Other - First Name:MICHELE
Other - Middle Name:ANN
Other - Last Name:LINDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:5256 SOUTH MISSION ROAD
Mailing Address - Street 2:SUITE 703-807
Mailing Address - City:BONSALL
Mailing Address - State:CA
Mailing Address - Zip Code:92003-6104
Mailing Address - Country:US
Mailing Address - Phone:760-472-3950
Mailing Address - Fax:760-472-3949
Practice Address - Street 1:5955 LAKE VISTA DR
Practice Address - Street 2:
Practice Address - City:BONSALL
Practice Address - State:CA
Practice Address - Zip Code:92003-6104
Practice Address - Country:US
Practice Address - Phone:760-472-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10658103TC0700X
CA103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical