MEDICARE: KAYLEEN MARIE 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	2020003145	MO

General Provider Information

NPI Number	:	1952926677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLEEN MARIE SHAW LCSW

Provider Business Mailing Address
First Line	:	4152 COUNTY ROAD 436
Second Line	:
City	:	JACKSON
State	:	MO
Zip	:	63755-8411
Country	:	US
Telephone Number	:	573-225-9226
Fax Number	:

Provider Business Practice Location Address
First Line	:	4152 COUNTY ROAD 436
Second Line	:
City	:	JACKSON
State	:	MO
Zip	:	63755-8411
Country	:	US
Telephone Number	:	573-225-9226
Fax Number	:

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

Provider Enumeration Date	:	06/09/2020
Last Update Date	:	06/09/2020

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