Provider Demographics
NPI:1801375423
Name:SHAW, MYRANDA JO
Entity Type:Individual
Prefix:
First Name:MYRANDA
Middle Name:JO
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 1:1751 SOUTHCROSS DR W
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-7012
Mailing Address - Country:US
Mailing Address - Phone:952-892-7690
Mailing Address - Fax:
Practice Address - Street 1:1751 SOUTHCROSS DR W
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-7012
Practice Address - Country:US
Practice Address - Phone:952-892-7690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CC01890101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health