Provider Demographics
NPI:1720060627
Name:SHAW, ELIZABETH A (PHD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:SHAW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 SWIFT AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4883
Mailing Address - Country:US
Mailing Address - Phone:919-824-2480
Mailing Address - Fax:919-416-1188
Practice Address - Street 1:112 SWIFT AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4883
Practice Address - Country:US
Practice Address - Phone:919-824-2480
Practice Address - Fax:919-416-1188
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1107103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC04534OtherBLUE CROSS BLUE SHIELD