Provider Demographics
NPI:1831341726
Name:SHAW, JUDITH LEE (LISW)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:LEE
Last Name:SHAW
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:686 CALLECITA JICARILLA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4940
Mailing Address - Country:US
Mailing Address - Phone:575-581-4728
Mailing Address - Fax:575-581-0030
Practice Address - Street 1:HWY 571 BLDG #28
Practice Address - Street 2:
Practice Address - City:EL RITO
Practice Address - State:NM
Practice Address - Zip Code:87530
Practice Address - Country:US
Practice Address - Phone:575-581-4728
Practice Address - Fax:575-581-0030
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-064031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical