Provider Demographics
NPI:1982727392
Name:SHAW, TRACY DENISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:DENISE
Last Name:SHAW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 GREEN VALLEY CIR
Mailing Address - Street 2:SUITE 109
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-6946
Mailing Address - Country:US
Mailing Address - Phone:310-641-3600
Mailing Address - Fax:
Practice Address - Street 1:5855 GREEN VALLEY CIR
Practice Address - Street 2:SUITE 109
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6946
Practice Address - Country:US
Practice Address - Phone:310-641-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 12548103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)