Provider Demographics
NPI:1962036293
Name:SHAW, LARRY (PHD)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 PALMERSTON PL APT 103
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-1833
Mailing Address - Country:US
Mailing Address - Phone:323-351-1185
Mailing Address - Fax:
Practice Address - Street 1:2215 N TOPANGA CANYON BLVD
Practice Address - Street 2:
Practice Address - City:TOPANGA
Practice Address - State:CA
Practice Address - Zip Code:90290-4312
Practice Address - Country:US
Practice Address - Phone:323-351-1185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT17578103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical