Provider Demographics
NPI:1689738064
Name:SHAW, KIMBERLY
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
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 1:17900 LINDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:ST. ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17900 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:ST. ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11435
Practice Address - Country:US
Practice Address - Phone:718-526-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY087621-1104100000X
NY085564-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker