Provider Demographics
NPI:1912194564
Name:SHAW, SUZANNE B
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:B
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 1:870 POLISADE AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3446
Mailing Address - Country:US
Mailing Address - Phone:201-767-4368
Mailing Address - Fax:201-767-6398
Practice Address - Street 1:870 POLISADE AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-3446
Practice Address - Country:US
Practice Address - Phone:201-767-4368
Practice Address - Fax:201-767-6398
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC011716001041C0700X
NYR0459581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical