MEDICARE: BRIAN SHAW PSYCHOTHERAPY, LLC

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	261QM0850X	Adult Mental Health Clinic/Center	1142 2826 1275	NE

General Provider Information

NPI Number	:	1417497355
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIAN SHAW PSYCHOTHERAPY, LLC

Provider Business Mailing Address
First Line	:	6910 PACIFIC ST
Second Line	:	320
City	:	OMAHA
State	:	NE
Zip	:	68106-1054
Country	:	US
Telephone Number	:	402-881-5475
Fax Number	:

Provider Business Practice Location Address
First Line	:	6910 PACIFIC ST
Second Line	:	320
City	:	OMAHA
State	:	NE
Zip	:	68106-1054
Country	:	US
Telephone Number	:	402-881-5475
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SOCIAL WORKER/OWNER
Name	:	MR. BRIAN KENNETH SHAW
Credential	:	LICSW, LIMHP
Telephone Number	:	402-881-5475

Provider Enumeration Date	:	02/26/2017
Last Update Date	:	02/26/2017

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