Basic Information
| Provider Information | |||||||||
| NPI: | 1346674124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | TIA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | BHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 SWEDEN ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CARIBOU | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047362127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074933366 | ||||||||
| FaxNumber: | 2074924889 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 SWEDEN ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CARIBOU | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047362127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074933366 | ||||||||
| FaxNumber: | 2074924889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2013 | ||||||||
| LastUpdateDate: | 08/20/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1346674124 | 05 | ME | MEDICAID |