Provider Demographics
NPI:1023724762
Name:SHAW, TYESHA
Entity type:Individual
Prefix:
First Name:TYESHA
Middle Name:
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 1:11321 WALTON LAKE RD
Mailing Address - Street 2:
Mailing Address - City:DISPUTANTA
Mailing Address - State:VA
Mailing Address - Zip Code:23842-4510
Mailing Address - Country:US
Mailing Address - Phone:804-930-3280
Mailing Address - Fax:
Practice Address - Street 1:11321 WALTON LAKE RD
Practice Address - Street 2:
Practice Address - City:DISPUTANTA
Practice Address - State:VA
Practice Address - Zip Code:23842-4510
Practice Address - Country:US
Practice Address - Phone:804-930-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA7094-07-006101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health