Provider Demographics
NPI:1790103224
Name:SHAW, AUDREY (MS)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 MEMORIAL CIR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4539
Mailing Address - Country:US
Mailing Address - Phone:931-920-7333
Mailing Address - Fax:
Practice Address - Street 1:403 GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-3711
Practice Address - Country:US
Practice Address - Phone:931-542-5057
Practice Address - Fax:931-503-3411
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TN000591828101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool