Provider Demographics
NPI:1245254317
Name:SHAW, PATRICIA (PHD)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 HOLLY GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-6531
Mailing Address - Country:US
Mailing Address - Phone:314-863-3588
Mailing Address - Fax:314-863-0074
Practice Address - Street 1:225 S MERAMEC AVE
Practice Address - Street 2:SUITE 506
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-3511
Practice Address - Country:US
Practice Address - Phone:314-863-3588
Practice Address - Fax:314-863-0074
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY01201103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493257802Medicaid