Provider Demographics
NPI:1316692692
Name:SHAW, GABRIELLE M (PBT,)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:M
Last Name:SHAW
Suffix:
Gender:F
Credentials:PBT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4795 BROADWAY STE D
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46409-2403
Mailing Address - Country:US
Mailing Address - Phone:219-331-5791
Mailing Address - Fax:
Practice Address - Street 1:4795 BROADWAY STE D
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-2403
Practice Address - Country:US
Practice Address - Phone:219-779-5939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YM0800X, 171M00000X, 246RM2200X, 251B00000X, 101YA0400X
IN60512246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical LaboratoryGroup - Single Specialty
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty
No251B00000XAgenciesCase Management