Provider Demographics
NPI:1154556918
Name:SHAW, MARK M (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:SHAW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9811
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-0811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 CALIFORNIA DR
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687
Practice Address - Country:US
Practice Address - Phone:707-449-6504
Practice Address - Fax:707-453-7047
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 15079103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic