Provider Demographics
NPI:1851185821
Name:SHAW, TAYLOR R
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:R
Last Name:SHAW
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6102
Mailing Address - Country:US
Mailing Address - Phone:860-705-0090
Mailing Address - Fax:
Practice Address - Street 1:63 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6102
Practice Address - Country:US
Practice Address - Phone:860-705-0090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician