Provider Demographics
NPI:1629239405
Name:SHAW, MIRANDA GRACE PERLEBERG (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:GRACE PERLEBERG
Last Name:SHAW
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 S BLISSFUL CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-1534
Mailing Address - Country:US
Mailing Address - Phone:720-891-6701
Mailing Address - Fax:
Practice Address - Street 1:4863 N NEVADA AVE STE 380
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3951
Practice Address - Country:US
Practice Address - Phone:719-255-8003
Practice Address - Fax:719-255-8075
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0003845103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical