Provider Demographics
NPI:1063649374
Name:SHAW, TIFFANY SHEREE (LCMHC,LPC, NCC, LCAS)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:SHEREE
Last Name:SHAW
Suffix:
Gender:F
Credentials:LCMHC,LPC, NCC, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 MOCKINGBIRD HILL RD
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-6363
Mailing Address - Country:US
Mailing Address - Phone:910-261-4635
Mailing Address - Fax:
Practice Address - Street 1:700 24TH ST
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:VA
Practice Address - Zip Code:23801-1716
Practice Address - Country:US
Practice Address - Phone:804-734-9623
Practice Address - Fax:804-734-9188
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2075101YA0400X
NC7366101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health