Provider Demographics
NPI:1578963302
Name:SHAW, KIMBERLY NEIBAUR
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:NEIBAUR
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 1:12040 98TH AVE NE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-4290
Mailing Address - Country:US
Mailing Address - Phone:425-658-3016
Mailing Address - Fax:425-658-3017
Practice Address - Street 1:12040 98TH AVE NE
Practice Address - Street 2:SUITE 204
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-4290
Practice Address - Country:US
Practice Address - Phone:425-658-3016
Practice Address - Fax:425-658-3017
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60470954101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor