MEDICARE: MR. GARY MARSHALL SHAW LCSW

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	1041C0700X	Clinical Social Worker	24493	TX

General Provider Information

NPI Number	:	1669667911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY MARSHALL SHAW LCSW

Provider Business Mailing Address
First Line	:	1511 W SAINT JOHNS AVE
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-1819
Country	:	US
Telephone Number	:	512-206-0837
Fax Number	:

Provider Business Practice Location Address
First Line	:	1511 W SAINT JOHNS AVE
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-1819
Country	:	US
Telephone Number	:	512-206-0837
Fax Number	:

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

Provider Enumeration Date	:	09/10/2007
Last Update Date	:	09/10/2007

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