Provider Demographics
NPI:1700136397
Name:SHAW, MARY (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 SE GRANT CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5838
Mailing Address - Country:US
Mailing Address - Phone:503-231-7515
Mailing Address - Fax:
Practice Address - Street 1:2901 FALK RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-6392
Practice Address - Country:US
Practice Address - Phone:360-313-3000
Practice Address - Fax:360-313-3001
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL 60321373235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist