Provider Demographics
NPI:1134266950
Name:SHAW, DAVID JONATHAN (PHD, LPC, CCDP)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JONATHAN
Last Name:SHAW
Suffix:
Gender:M
Credentials:PHD, LPC, CCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 QUIGLEY AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-3609
Mailing Address - Country:US
Mailing Address - Phone:215-657-1416
Mailing Address - Fax:215-657-0679
Practice Address - Street 1:519 QUIGLEY AVE
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-3609
Practice Address - Country:US
Practice Address - Phone:215-657-1416
Practice Address - Fax:215-657-0679
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC002748101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional