Provider Demographics
NPI:1689640815
Name:SHAW, THERESA (MS)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 1ST AVE
Mailing Address - Street 2:SUITE 3E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:212-263-7349
Mailing Address - Fax:
Practice Address - Street 1:530 1ST AVE
Practice Address - Street 2:SUITE 3E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-7349
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001593231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYM25111Medicare ID - Type Unspecified
NYS42623Medicare UPIN