Provider Demographics
NPI:1073689659
Name:SHAW, SIDNEY L (LCPC)
Entity Type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:L
Last Name:SHAW
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 SW HIGGINS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1420
Mailing Address - Country:US
Mailing Address - Phone:406-203-2150
Mailing Address - Fax:
Practice Address - Street 1:725 SW HIGGINS AVE STE B
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1420
Practice Address - Country:US
Practice Address - Phone:406-203-2150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK398101YM0800X
MT1456101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCL3490Medicaid