Healthcare Provider Details

I. General information

NPI: 1215072103
Provider Name (Legal Business Name): LAURA Z SHAW LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 CHURCH ST
NEWTON MA
02458-2004
US

IV. Provider business mailing address

116 CHURCH ST
NEWTON MA
02458-2004
US

V. Phone/Fax

Practice location:
  • Phone: 617-964-3813
  • Fax: 617-795-0313
Mailing address:
  • Phone: 617-964-3813
  • Fax: 617-795-0313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1024583
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1024583
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerSOCIAL WORK LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: