MEDICARE: DIANE ELLEN SHAW CADAC LL

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	A014670315	CA

General Provider Information

NPI Number	:	1225698954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE ELLEN SHAW CADAC LL

Provider Business Mailing Address
First Line	:	17261 GOTHARD ST SPC 9
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-5454
Country	:	US
Telephone Number	:	714-604-5281
Fax Number	:	714-547-2109

Provider Business Practice Location Address
First Line	:	1950 E 17TH ST
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92705-6852
Country	:	US
Telephone Number	:	714-547-4300
Fax Number	:	714-547-2109

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

Provider Enumeration Date	:	06/14/2019
Last Update Date	:	06/14/2019

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