Provider Demographics
NPI:1386312783
Name:SHAW, KYALAI A (SUDRC)
Entity type:Individual
Prefix:MISS
First Name:KYALAI
Middle Name:A
Last Name:SHAW
Suffix:
Gender:F
Credentials:SUDRC
Other - Prefix:MISS
Other - First Name:KIKI
Other - Middle Name:
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RBT
Mailing Address - Street 1:1200 CONCORD AVE STE CONCORD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4915
Mailing Address - Country:US
Mailing Address - Phone:510-268-8120
Mailing Address - Fax:
Practice Address - Street 1:3845 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2419
Practice Address - Country:US
Practice Address - Phone:510-450-1197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-20-142531106S00000X
CA16183101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician