Provider Demographics
NPI:1073535217
Name:SHAW, WILLIE JR (EDS MA)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:SHAW
Suffix:JR
Gender:M
Credentials:EDS MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 TEAGUE RD APT 507
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-6359
Mailing Address - Country:US
Mailing Address - Phone:843-293-2976
Mailing Address - Fax:
Practice Address - Street 1:164 WACCAMAW MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8903
Practice Address - Country:US
Practice Address - Phone:843-347-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor