Provider Demographics
NPI:1194258061
Name:SHAW, SHANTAE MONIQUE
Entity type:Individual
Prefix:
First Name:SHANTAE
Middle Name:MONIQUE
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E25 MILL POND RD
Mailing Address - Street 2:
Mailing Address - City:BROAD BROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06016-9107
Mailing Address - Country:US
Mailing Address - Phone:860-987-3035
Mailing Address - Fax:
Practice Address - Street 1:258 OLD LYMAN RD
Practice Address - Street 2:
Practice Address - City:SOUTH HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01075-2653
Practice Address - Country:US
Practice Address - Phone:413-896-9094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker