Provider Demographics
NPI:1710759493
Name:SHAW, SHANE A
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:A
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 RIDGELAKE DR STE 309A
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-4938
Mailing Address - Country:US
Mailing Address - Phone:504-309-0259
Mailing Address - Fax:504-309-2702
Practice Address - Street 1:3100 RIDGELAKE DR STE 309A
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-4938
Practice Address - Country:US
Practice Address - Phone:504-309-0259
Practice Address - Fax:504-309-2702
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty