Provider Demographics
NPI:1336684844
Name:SHAW, GREGORY (BCABA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 SCIENCE PKWY
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-5506
Mailing Address - Country:US
Mailing Address - Phone:571-374-8066
Mailing Address - Fax:517-374-5912
Practice Address - Street 1:2400 SCIENCE PKWY
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-5506
Practice Address - Country:US
Practice Address - Phone:571-374-8066
Practice Address - Fax:517-374-5912
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0-16-7437106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst