Provider Demographics
NPI:1982740627
Name:SHAW, LISA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
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 1:56 MARSHAL ST # 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5423
Mailing Address - Country:US
Mailing Address - Phone:617-277-6286
Mailing Address - Fax:617-277-6286
Practice Address - Street 1:344 HARVARD ST
Practice Address - Street 2:SUITE #1
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-2917
Practice Address - Country:US
Practice Address - Phone:617-277-6286
Practice Address - Fax:617-277-6286
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3659103G00000X, 103TB0200X, 103TC0700X, 103TC2200X, 103TF0000X, 103TH0100X, 103TM1800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0514489Medicaid
MAW03688OtherBCBSMA PROVIDER NUMBER