Provider Demographics
NPI:1518046374
Name:SHAW, KATIE ANN LOUISE (LICSW)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ANN LOUISE
Last Name:SHAW
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ANN LOUISE
Other - Last Name:TILLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1875 STATION PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3319
Mailing Address - Country:US
Mailing Address - Phone:763-482-9598
Mailing Address - Fax:
Practice Address - Street 1:1875 STATION PKWY NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3319
Practice Address - Country:US
Practice Address - Phone:763-482-9598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN16455LICSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
061637100OtherMEDICAL ASSISTANCE MA