Provider Demographics
NPI:1629106703
Name:SHAW, EMMA LETICIA (MFC44065)
Entity Type:Individual
Prefix:DR
First Name:EMMA
Middle Name:LETICIA
Last Name:SHAW
Suffix:
Gender:F
Credentials:MFC44065
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:LETICIA
Other - Last Name:CARDENAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4951
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-0951
Mailing Address - Country:US
Mailing Address - Phone:909-861-6517
Mailing Address - Fax:
Practice Address - Street 1:535 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3013
Practice Address - Country:US
Practice Address - Phone:626-974-0770
Practice Address - Fax:626-974-0774
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC44065106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist