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General NPI Number Information
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NPI Number | 1093661241
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Entity Type | Organization
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Legal Business Name | PROUD MENTAL HEALTH LLC
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Dates
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Enumeration Date | 03/09/2026
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Last Update Date | 03/09/2026
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Provider Practice Location Address
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Address Line | 1309 COFFEEN AVE # 19118
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City | SHERIDAN
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State | WY
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Zip | 82801-5777
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Country | US
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Telephone | 657-229-5479
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Fax |
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Provider Business Mailing Address
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Address Line | 1309 COFFEEN AVE # 19118
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City | SHERIDAN
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State | WY
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Zip | 82801-5777
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | JONATHAN WAYNE SHAW
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Credential | PMHNP
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Telephone | 657-229-5479
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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