Provider Demographics
NPI:1972841047
Name:SHAW, LEE (LMFT)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 CANYON CREST DR STE 253
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6326
Mailing Address - Country:US
Mailing Address - Phone:951-500-9658
Mailing Address - Fax:951-343-5601
Practice Address - Street 1:5225 CANYON CREST DR STE 253
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-6326
Practice Address - Country:US
Practice Address - Phone:951-500-9658
Practice Address - Fax:951-346-5601
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97306106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1972841047Medicaid
CA97306OtherLMFT