Provider Demographics
NPI:1740796531
Name:LEE SHAW JR, LLC
Entity Type:Organization
Organization Name:LEE SHAW JR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:JR
Authorized Official - Credentials:LMFT
Authorized Official - Phone:951-500-9658
Mailing Address - Street 1:6809 INDIANA AVE STE 166
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4221
Mailing Address - Country:US
Mailing Address - Phone:951-500-9658
Mailing Address - Fax:951-346-5601
Practice Address - Street 1:6809 INDIANA AVE STE 166
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4221
Practice Address - Country:US
Practice Address - Phone:951-500-9658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-16
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97306106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA97306OtherLMFT