Provider Demographics
NPI:1912385469
Name:SHAW, MICHELLE ANN
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANN
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:SCHULTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12440 FIRESTONE BLVD STE 316
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-9319
Mailing Address - Country:US
Mailing Address - Phone:562-864-3722
Mailing Address - Fax:562-864-4596
Practice Address - Street 1:12440 FIRESTONE BLVD STE 316
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-9319
Practice Address - Country:US
Practice Address - Phone:562-864-3722
Practice Address - Fax:562-864-4596
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CAIMF84641101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner