Provider Demographics
NPI:1861032609
Name:SHAW, AUDREY B (ALC)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:B
Last Name:SHAW
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:A
Other - Last Name:BRABHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ALC
Mailing Address - Street 1:8104 SEATON PL
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-7204
Mailing Address - Country:US
Mailing Address - Phone:334-272-3889
Mailing Address - Fax:334-272-4089
Practice Address - Street 1:8104 SEATON PL
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-7204
Practice Address - Country:US
Practice Address - Phone:334-272-3889
Practice Address - Fax:334-272-4089
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC3364A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor