Basic Information
Provider Information | |||||||||
NPI: | 1417430943 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHAW | ||||||||
FirstName: | AMBER | ||||||||
MiddleName: | DALE KONIA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 242 GREEN LEA PL | ||||||||
Address2: |   | ||||||||
City: | THOUSAND OAKS | ||||||||
State: | CA | ||||||||
PostalCode: | 913611101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3104240637 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 19634 VENTURA BLVD STE 212 | ||||||||
Address2: |   | ||||||||
City: | TARZANA | ||||||||
State: | CA | ||||||||
PostalCode: | 913562984 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8187589450 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/11/2018 | ||||||||
LastUpdateDate: | 09/11/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 107737 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 107737 | 01 | CA | BOARD OF BEHAVIOR SCIENCES | OTHER |