Provider Demographics
NPI:1407567704
Name:SHAW, JOSEPH III
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:SHAW
Suffix:III
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 1:9620 S PARNELL AVE # 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1136
Mailing Address - Country:US
Mailing Address - Phone:312-983-2684
Mailing Address - Fax:
Practice Address - Street 1:1710 N FULLER AVE APT 436
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046-3066
Practice Address - Country:US
Practice Address - Phone:312-983-2684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0Medicaid