Provider Demographics
NPI:1821300682
Name:SHAW, AMIE LYN (BA, CBHCM 1)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:LYN
Last Name:SHAW
Suffix:
Gender:F
Credentials:BA, CBHCM 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2242 NW 39TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-8884
Mailing Address - Country:US
Mailing Address - Phone:405-602-3171
Mailing Address - Fax:
Practice Address - Street 1:2242 NW 39TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-8884
Practice Address - Country:US
Practice Address - Phone:405-602-3171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9700171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator