MEDICARE: LISA MONIQUE SHAW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	IMF81259	CA

General Provider Information

NPI Number	:	1164830089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MONIQUE SHAW

Provider Business Mailing Address
First Line	:	45 WILDER ST APT 4
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94131-3077
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	45 WILDER ST APT 4
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94131-3077
Country	:	US
Telephone Number	:	916-769-5356
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2014
Last Update Date	:	12/28/2020

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