Provider Demographics
NPI:1437725603
Name:DIEDRE SHAW LLC
Entity Type:Organization
Organization Name:DIEDRE SHAW LLC
Other - Org Name:DIEDRE SHAW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ASIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-413-1684
Mailing Address - Street 1:245 S 84TH ST STE L101
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2601
Mailing Address - Country:US
Mailing Address - Phone:402-326-9168
Mailing Address - Fax:833-587-9383
Practice Address - Street 1:245 S 84TH ST STE L101
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2601
Practice Address - Country:US
Practice Address - Phone:402-326-9168
Practice Address - Fax:402-261-6319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-28
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026878800Medicaid