Provider Demographics
NPI:1639543259
Name:SHAW, IMANI
Entity type:Individual
Prefix:
First Name:IMANI
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 1:3985 ARKWRIGHT RD STE 106
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1775
Mailing Address - Country:US
Mailing Address - Phone:478-477-2070
Mailing Address - Fax:478-474-0170
Practice Address - Street 1:3985 ARKWRIGHT RD STE 106
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1775
Practice Address - Country:US
Practice Address - Phone:478-477-2070
Practice Address - Fax:478-474-0170
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health