Provider Demographics
NPI:1972347516
Name:SHAW, KRISTIE LEE
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:LEE
Last Name:SHAW
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:LEE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1007 KOALA DR
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-9247
Mailing Address - Country:US
Mailing Address - Phone:509-826-6191
Mailing Address - Fax:
Practice Address - Street 1:1007 KOALA DR
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9247
Practice Address - Country:US
Practice Address - Phone:509-826-6191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-19
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101Y00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor