Provider Demographics
NPI:1912129545
Name:SHAW, CRISTINA LEE (PHD, MSW)
Entity type:Individual
Prefix:DR
First Name:CRISTINA
Middle Name:LEE
Last Name:SHAW
Suffix:
Gender:F
Credentials:PHD, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 536
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80502-0536
Mailing Address - Country:US
Mailing Address - Phone:303-775-7221
Mailing Address - Fax:
Practice Address - Street 1:3050 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3154
Practice Address - Country:US
Practice Address - Phone:303-775-7221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2363-C1041C0700X
AR10-37 AP-PL103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical