MEDICARE: SHAW MINDFUL MEDICINE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1679430326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHAW MINDFUL MEDICINE PLLC

Provider Business Mailing Address
First Line	:	606 GREEN MEADOW DR
Second Line	:
City	:	DOUGLASSVILLE
State	:	PA
Zip	:	19518-1344
Country	:	US
Telephone Number	:	917-575-5662
Fax Number	:	844-739-1051

Provider Business Practice Location Address
First Line	:	701 E CATHEDRAL RD STE 45
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19128-2128
Country	:	US
Telephone Number	:	917-575-5662
Fax Number	:	844-739-1051

Authorized Official
Title or Position	:	OWNER
Name	:	JUSTIN WILLIAM SHAW
Credential	:	NP-P, PMHNP-BC
Telephone Number	:	917-575-5662

Provider Enumeration Date	:	01/06/2026
Last Update Date	:	01/06/2026

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