Provider Demographics
NPI:1073857124
Name:SHAH, FRED THOMAS PAUL (LCMHC, LCASA)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:THOMAS PAUL
Last Name:SHAH
Suffix:
Gender:M
Credentials:LCMHC, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610-A S. COLLEGE ROAD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403
Mailing Address - Country:US
Mailing Address - Phone:910-796-2490
Mailing Address - Fax:910-202-9966
Practice Address - Street 1:610-A S. COLLEGE ROAD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6431
Practice Address - Country:US
Practice Address - Phone:910-796-2490
Practice Address - Fax:910-202-9966
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21403101YA0400X, 101YP2500X
NC9687101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty