Healthcare Provider Details

I. General information

NPI: 1164206355
Provider Name (Legal Business Name): MS. TIARA SHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3542 BROOKSTONE DR APT C
CINCINNATI OH
45209-1171
US

IV. Provider business mailing address

9420 TOWNE SQUARE AVE
BLUE ASH OH
45242-6922
US

V. Phone/Fax

Practice location:
  • Phone: 513-570-0872
  • Fax:
Mailing address:
  • Phone: 513-399-2214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberFSP000256
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: