Provider Demographics
NPI:1730679333
Name:SHAW, DOMINIQUE
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
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 1:209 N BROAD ST STE A
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-5507
Mailing Address - Country:US
Mailing Address - Phone:504-577-1154
Mailing Address - Fax:
Practice Address - Street 1:209 N BROAD ST STE A
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-5507
Practice Address - Country:US
Practice Address - Phone:504-577-1154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator