Provider Demographics
NPI:1538475926
Name:SHAW, JOHN ROBERT
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROBERT
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:J
Other - Middle Name:ROBERT
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:601 ABBOT RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-3366
Mailing Address - Country:US
Mailing Address - Phone:517-230-1993
Mailing Address - Fax:
Practice Address - Street 1:601 ABBOT RD
Practice Address - Street 2:SUITE 103
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-3366
Practice Address - Country:US
Practice Address - Phone:517-230-1993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010920691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical