Provider Demographics
NPI:1417614348
Name:SHAW, VANESSA BOUIE
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:BOUIE
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 1:510 UPTAIN RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32352-6568
Mailing Address - Country:US
Mailing Address - Phone:850-597-5784
Mailing Address - Fax:
Practice Address - Street 1:510 UPTAIN RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32352-6568
Practice Address - Country:US
Practice Address - Phone:850-597-5784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-28
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker