Provider Demographics
NPI:1710415161
Name:SHAW, RACHAEL
Entity Type:Individual
Prefix:
First Name:RACHAEL
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 1:104 1/2 E ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-4308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 E MADISON AVE STE 6
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-4712
Practice Address - Country:US
Practice Address - Phone:307-851-3955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator