Basic Information
| Provider Information | |||||||||
| NPI: | 1003405739 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4531 N 16TH ST STE 114 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850165344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022668700 | ||||||||
| FaxNumber: | 6022960404 | ||||||||
| Practice Location | |||||||||
| Address1: | 18555 N 79TH AVE STE D107 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853086040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6237773477 | ||||||||
| FaxNumber: | 6237773478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2021 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 262350 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.