MEDICARE: DR. TIMOTHY S SHAW PHD

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	103TC1900X	Counseling Psychologist	PY2148	FL

General Provider Information

NPI Number	:	1811959331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY S SHAW PHD

Provider Business Mailing Address
First Line	:	136 JULIA ST UNIT 100
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-7713
Country	:	US
Telephone Number	:	386-423-9161
Fax Number	:	386-423-3094

Provider Business Practice Location Address
First Line	:	136 JULIA ST UNIT 100
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-7713
Country	:	US
Telephone Number	:	386-423-9161
Fax Number	:	386-423-3094

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

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	07/01/2020

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