MEDICARE: DANTE SANDLIN 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	103TC0700X	Clinical Psychologist	0001314	GA

General Provider Information

NPI Number	:	1841366630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANTE SANDLIN SHAW PH.D.

Provider Business Mailing Address
First Line	:	2120 LAUREL LAKE DR
Second Line	:
City	:	SUWANEE
State	:	GA
Zip	:	30024-4317
Country	:	US
Telephone Number	:	404-556-4226
Fax Number	:	770-963-7490

Provider Business Practice Location Address
First Line	:	750 LONGLEAF BLVD
Second Line	:	SUITE D
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30045-8459
Country	:	US
Telephone Number	:	404-556-4226
Fax Number	:	770-963-7490

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

Provider Enumeration Date	:	11/26/2006
Last Update Date	:	07/08/2007

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