Provider Demographics
NPI:1093943425
Name:SHAW, SHENETHIA FENNER (LCMHCS, NCC)
Entity Type:Individual
Prefix:MRS
First Name:SHENETHIA
Middle Name:FENNER
Last Name:SHAW
Suffix:
Gender:F
Credentials:LCMHCS, NCC
Other - Prefix:
Other - First Name:SHENETHIA
Other - Middle Name:FENNER
Other - Last Name:HEBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:305 ABBOTTSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-3369
Mailing Address - Country:US
Mailing Address - Phone:910-227-9779
Mailing Address - Fax:
Practice Address - Street 1:305 ABBOTTSWOOD DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-3369
Practice Address - Country:US
Practice Address - Phone:910-227-9779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-24
Last Update Date:2020-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7614101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104409Medicaid