MEDICARE: DR. DAVID BRIAN SHAW PH.D.

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	103T00000X	Psychologist	0810004175	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0810004175	OTHER	VA	CLINICAL PSYCHOLOGIST LICENSE

General Provider Information

NPI Number	:	1376542241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID BRIAN SHAW PH.D.

Provider Business Mailing Address
First Line	:	5007C VICTORY BLVD # 387
Second Line	:
City	:	YORKTOWN
State	:	VA
Zip	:	23693-5601
Country	:	US
Telephone Number	:	757-788-9141
Fax Number	:

Provider Business Practice Location Address
First Line	:	611 IRONWOOD DR
Second Line	:
City	:	YORKTOWN
State	:	VA
Zip	:	23693-5560
Country	:	US
Telephone Number	:	757-788-9141
Fax Number	:

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

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	12/14/2021

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