Provider Demographics
NPI:1730283912
Name:SHAW, ELISA (LCSW)
Entity type:Individual
Prefix:
First Name:ELISA
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 1:30 HEMPSTEAD AVE
Mailing Address - Street 2:SUITE H-4
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4033
Mailing Address - Country:US
Mailing Address - Phone:516-456-0993
Mailing Address - Fax:516-442-0380
Practice Address - Street 1:30 HEMPSTEAD AVE
Practice Address - Street 2:SUITE H-4
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4033
Practice Address - Country:US
Practice Address - Phone:516-456-0993
Practice Address - Fax:516-442-0380
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0711941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYES0N34P710Medicare UPIN