=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548548951
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAYLA SHAW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2011
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18321 CLARK ST
-----------------------------------------------------
City | TARZANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91356-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-648-9533
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11856 BALBOA BLVD # 154
-----------------------------------------------------
City | GRANADA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91344-2753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-648-9533
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 71186
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------