Provider Demographics
NPI:1780853150
Name:SHAW, DOUGLAS LYNDE (PSYD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LYNDE
Last Name:SHAW
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 S PLEASANT VALLEY RD
Mailing Address - Street 2:SUITE 918
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-4688
Mailing Address - Country:US
Mailing Address - Phone:512-839-5155
Mailing Address - Fax:
Practice Address - Street 1:2830 REAL ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78722-1715
Practice Address - Country:US
Practice Address - Phone:512-448-1840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37052103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical