Provider Demographics
NPI:1821459223
Name:SHAW, WESLEY LEWIS (MAT, BCBA, LBA)
Entity Type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:LEWIS
Last Name:SHAW
Suffix:
Gender:M
Credentials:MAT, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 PHOENIX DR STE 115
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7392
Mailing Address - Country:US
Mailing Address - Phone:757-932-7598
Mailing Address - Fax:757-743-9004
Practice Address - Street 1:629 PHOENIX DR STE 115
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7392
Practice Address - Country:US
Practice Address - Phone:757-932-9057
Practice Address - Fax:757-743-9004
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-16425103K00000X
VA0133000525103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst