Provider Demographics
NPI:1417409152
Name:SHAW, URSULA
Entity Type:Individual
Prefix:
First Name:URSULA
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 1:10105 PLANK RD STE A
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-3707
Mailing Address - Country:US
Mailing Address - Phone:225-244-7026
Mailing Address - Fax:
Practice Address - Street 1:10105 PLANK RD. STE A
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:LA
Practice Address - Zip Code:70722
Practice Address - Country:US
Practice Address - Phone:225-244-7026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health