Provider Demographics
NPI:1558973586
Name:SHAW, MAIZIE MARIE
Entity Type:Individual
Prefix:
First Name:MAIZIE
Middle Name:MARIE
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2338
Mailing Address - Country:US
Mailing Address - Phone:315-426-3600
Mailing Address - Fax:315-426-7793
Practice Address - Street 1:660 MADISON STREET
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:315-426-7680
Practice Address - Fax:315-426-7793
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0895721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical