Provider Demographics
NPI:1790103224
Name:SHAW, AUDREY (MS)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:123 WORTHING RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:ME
Mailing Address - Zip Code:04351-3234
Mailing Address - Country:US
Mailing Address - Phone:207-530-1995
Mailing Address - Fax:
Practice Address - Street 1:16 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-1900
Practice Address - Country:US
Practice Address - Phone:603-883-0005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC5017101Y00000X, 101YP2500X
101YM0800X
TN000591828101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool