Healthcare Provider Details

I. General information

NPI: 1548097645
Provider Name (Legal Business Name): JOHN SHAW LMHCA
Entity Type: Individual
Gender:
Sole Proprietor: Y

Provider Other Name: JACK SHAW

II. Dates (important events)

Enumeration Date: 09/14/2024
Last Update Date: 09/14/2024
Certification Date: 09/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SHIMOMEGURO 6-20-6-304
MEGURO ZZ - FOREIGN COUNTRIES
1530064
JP

IV. Provider business mailing address

SHIMOMEGURO 6-20-6-304
MEGURO ZZ - FOREIGN COUNTRIES
1530064
JP

V. Phone/Fax

Practice location:
  • Phone: 80-537-7823
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC61582723
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: