Provider Demographics
NPI:1821550336
Name:SHAW, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
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 1:2909 ROUTE 100 STE 110
Mailing Address - Street 2:
Mailing Address - City:OREFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:18069-2951
Mailing Address - Country:US
Mailing Address - Phone:570-460-0050
Mailing Address - Fax:
Practice Address - Street 1:2909 ROUTE 100 STE 110
Practice Address - Street 2:
Practice Address - City:OREFIELD
Practice Address - State:PA
Practice Address - Zip Code:18069-2951
Practice Address - Country:US
Practice Address - Phone:570-460-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
PABH005074103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician