MEDICARE: LYMAR 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	104100000X	Social Worker	S000521772940	FL
2	1041C0700X	Clinical Social Worker	S000521772940	FL

General Provider Information

NPI Number	:	1568708048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYMAR SHAW

Provider Business Mailing Address
First Line	:	6222 NW GISELA ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-3867
Country	:	US
Telephone Number	:	561-294-8900
Fax Number	:

Provider Business Practice Location Address
First Line	:	6222 NW GISELA ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-3867
Country	:	US
Telephone Number	:	561-294-8900
Fax Number	:

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

Provider Enumeration Date	:	01/02/2013
Last Update Date	:	01/02/2013

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