Healthcare Provider Details

I. General information

NPI: 1093661241
Provider Name (Legal Business Name): PROUD MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 COFFEEN AVE # 19118
SHERIDAN WY
82801-5777
US

IV. Provider business mailing address

1309 COFFEEN AVE # 19118
SHERIDAN WY
82801-5777
US

V. Phone/Fax

Practice location:
  • Phone: 657-229-5479
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN WAYNE SHAW
Title or Position: OWNER/CEO
Credential: PMHNP
Phone: 657-229-5479