Provider Demographics
NPI:1497741284
Name:SHAW, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18384 LOST LAKE WAY
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-3805
Mailing Address - Country:US
Mailing Address - Phone:561-444-7038
Mailing Address - Fax:561-746-6036
Practice Address - Street 1:18384 LOST LAKE WAY
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-3805
Practice Address - Country:US
Practice Address - Phone:561-444-7038
Practice Address - Fax:561-746-6036
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0003539103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75600AMedicare ID - Type Unspecified