Healthcare Provider Details

I. General information

NPI: 1437725603
Provider Name (Legal Business Name): DIEDRE SHAW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N 48TH ST STE A
LINCOLN NE
68504-3515
US

IV. Provider business mailing address

330 N 48TH ST STE A
LINCOLN NE
68504-3515
US

V. Phone/Fax

Practice location:
  • Phone: 402-326-9168
  • Fax: 402-817-1172
Mailing address:
  • Phone: 402-326-9168
  • Fax: 402-817-1172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: ASIA ALI
Title or Position: BILLING SPECIALIST
Credential:
Phone: 402-413-1684