Healthcare Provider Details

I. General information

NPI: 1295318541
Provider Name (Legal Business Name): DIANA GAIL SHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA GAIL STINSON

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 VIKING DR
SACRAMENTO CA
95827-2844
US

IV. Provider business mailing address

2581 CARSON WAY
SACRAMENTO CA
95821-4702
US

V. Phone/Fax

Practice location:
  • Phone: 916-912-0362
  • Fax:
Mailing address:
  • Phone: 916-494-8641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number70218
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: