Provider Demographics
NPI:1447763453
Name:SHAW, LAURA LOUISE (LMFT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LOUISE
Last Name:SHAW
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4127 BAYARD ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5006
Mailing Address - Country:US
Mailing Address - Phone:760-519-6060
Mailing Address - Fax:
Practice Address - Street 1:4425 CASS ST STE K
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-4015
Practice Address - Country:US
Practice Address - Phone:760-519-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40149106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist