Provider Demographics
NPI:1821800111
Name:SHAW, ELYSSA LORRAINE (ASW11761)
Entity type:Individual
Prefix:
First Name:ELYSSA
Middle Name:LORRAINE
Last Name:SHAW
Suffix:
Gender:F
Credentials:ASW11761
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21810 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5810
Mailing Address - Country:US
Mailing Address - Phone:909-580-5006
Mailing Address - Fax:
Practice Address - Street 1:21810 MAIN ST
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5810
Practice Address - Country:US
Practice Address - Phone:909-580-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW11761101YM0800X
ASW117611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health