Provider Demographics
NPI:1104997568
Name:SHAW, BEVERLY L (PH D)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:L
Last Name:SHAW
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1768 GLENDON AVE
Mailing Address - Street 2:#1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5740
Mailing Address - Country:US
Mailing Address - Phone:310-470-9422
Mailing Address - Fax:310-470-4606
Practice Address - Street 1:1722 WESTWOOD BLVD
Practice Address - Street 2:STE 103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-5637
Practice Address - Country:US
Practice Address - Phone:310-470-2247
Practice Address - Fax:310-470-4606
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAMFC209661103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist