Provider Demographics
NPI:1003239963
Name:SHAW, ELIZABETH MAGANA (LMSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MAGANA
Last Name:SHAW
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 RIVERBANK ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-3834
Mailing Address - Country:US
Mailing Address - Phone:313-268-4454
Mailing Address - Fax:
Practice Address - Street 1:13101 ALLEN RD STE 500
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-785-7700
Practice Address - Fax:734-287-1953
Is Sole Proprietor?:No
Enumeration Date:2014-01-29
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801087916101YM0800X, 1041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1710286836Medicaid