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General NPI Number Information
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NPI Number | 1740796531
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Entity Type | Organization
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Legal Business Name | LEE SHAW JR, LLC
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Dates
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Enumeration Date | 12/16/2017
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Last Update Date | 11/05/2018
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Provider Practice Location Address
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Address Line | 6809 INDIANA AVE STE 166
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City | RIVERSIDE
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State | CA
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Zip | 92506-4221
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Country | US
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Telephone | 951-500-9658
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Fax |
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Provider Business Mailing Address
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Address Line | 6809 INDIANA AVE STE 166
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City | RIVERSIDE
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State | CA
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Zip | 92506-4221
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Country | US
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Telephone | 951-500-9658
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Fax | 951-346-5601
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Authorized Official
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Title or Position | OWNER
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Name | LEE SHAW JR.
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Credential | LMFT
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Telephone | 951-500-9658
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 97306
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License Number State | CA
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