Provider Demographics
NPI:1538123443
Name:SHAW, THOMAS W (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:SHAW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S IDAHO ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-6047
Mailing Address - Country:US
Mailing Address - Phone:562-690-0400
Mailing Address - Fax:562-501-1198
Practice Address - Street 1:501 S IDAHO ST
Practice Address - Street 2:SUITE 250
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-6047
Practice Address - Country:US
Practice Address - Phone:560-690-0400
Practice Address - Fax:562-501-1198
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 8126103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY8126Medicare UPIN
CAPSY8126AMedicare ID - Type Unspecified