Provider Demographics
NPI:1992100192
Name:SHAW, ANDREA (LCSW)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 16TH ST
Mailing Address - Street 2:APT. 10G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3707
Mailing Address - Country:US
Mailing Address - Phone:212-533-5614
Mailing Address - Fax:
Practice Address - Street 1:200 E 16TH ST
Practice Address - Street 2:APT. 10G
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3707
Practice Address - Country:US
Practice Address - Phone:212-533-5614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2015-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080980-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300119470Medicare PIN