Provider Demographics
NPI:1851712798
Name:JOHN ROBERT SHAW
Entity Type:Organization
Organization Name:JOHN ROBERT SHAW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:S
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-483-2461
Mailing Address - Street 1:601 ABBOT RD STE 103
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-3366
Mailing Address - Country:US
Mailing Address - Phone:517-574-4197
Mailing Address - Fax:517-574-4201
Practice Address - Street 1:601 ABBOT RD STE 103
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-3366
Practice Address - Country:US
Practice Address - Phone:517-574-4197
Practice Address - Fax:517-574-4201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010920691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty