Provider Demographics
NPI:1881570331
Name:SHADOW, BURTON ALEXANDER
Entity type:Individual
Prefix:
First Name:BURTON
Middle Name:ALEXANDER
Last Name:SHADOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 MANDERLY PL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4520
Mailing Address - Country:US
Mailing Address - Phone:817-739-8174
Mailing Address - Fax:
Practice Address - Street 1:3540 MANDERLY PL
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4520
Practice Address - Country:US
Practice Address - Phone:817-739-8174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX352091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical