Healthcare Provider Details

I. General information

NPI: 1346665478
Provider Name (Legal Business Name): SHAUNDRA SHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 LAKE SPRINGS LN
CORDOVA TN
38016-5328
US

IV. Provider business mailing address

2210 LAKE SPRINGS LN
CORDOVA TN
38016-5328
US

V. Phone/Fax

Practice location:
  • Phone: 901-831-0462
  • Fax: 901-531-8026
Mailing address:
  • Phone: 901-831-0462
  • Fax: 901-531-8026

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 Code172V00000X
TaxonomyCommunity Health Worker
License Number1000000010766
License Number StateTN

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: