Provider Demographics
NPI:1689794000
Name:SHAW, VERNELL III (ASW)
Entity Type:Individual
Prefix:
First Name:VERNELL
Middle Name:
Last Name:SHAW
Suffix:III
Gender:M
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 S. GRANT STREET
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206
Mailing Address - Country:US
Mailing Address - Phone:209-468-1210
Mailing Address - Fax:
Practice Address - Street 1:1414 NORTH CALIFORNIA STREET
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202
Practice Address - Country:US
Practice Address - Phone:209-468-2385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 19507104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker