Provider Demographics
NPI:1447800412
Name:SHAW, MELISSA CLARE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CLARE
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANNE OLIVIA
Other - Last Name:CLARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1834
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-1834
Mailing Address - Country:US
Mailing Address - Phone:562-686-8660
Mailing Address - Fax:
Practice Address - Street 1:478 MAVERICK LN
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-6575
Practice Address - Country:US
Practice Address - Phone:562-686-8660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT113382101YM0800X, 106H00000X
CALMFT141102106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health