Provider Demographics
NPI:1346665478
Name:SHAW, SHAUNDRA
Entity Type:Individual
Prefix:
First Name:SHAUNDRA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 LAKE SPRINGS LN
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-5328
Mailing Address - Country:US
Mailing Address - Phone:901-831-0462
Mailing Address - Fax:901-531-8026
Practice Address - Street 1:2210 LAKE SPRINGS LN
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-5328
Practice Address - Country:US
Practice Address - Phone:901-831-0462
Practice Address - Fax:901-531-8026
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TN1000000010766172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker