Healthcare Provider Details

I. General information

NPI: 1225380611
Provider Name (Legal Business Name): CARLIE SHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 W 3RD AVE SUITE 103
ANCHORAGE AK
99501-2236
US

IV. Provider business mailing address

509 W 3RD AVE SUITE 103
ANCHORAGE AK
99501-2236
US

V. Phone/Fax

Practice location:
  • Phone: 907-279-9634
  • Fax: 907-276-5489
Mailing address:
  • Phone: 907-279-9634
  • Fax: 907-276-5489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: