Provider Demographics
NPI:1932611357
Name:SHAW, JUSTIN WILLIAM (NP-P, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WILLIAM
Last Name:SHAW
Suffix:
Gender:M
Credentials:NP-P, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FRANKLIN AVE APT 1B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-3554
Mailing Address - Country:US
Mailing Address - Phone:917-575-5662
Mailing Address - Fax:
Practice Address - Street 1:3425 VERNON BLVD
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-5121
Practice Address - Country:US
Practice Address - Phone:917-575-5662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY403664363LP0808X
NY711620163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)