Provider Demographics
NPI:1124210596
Name:SHAW, MARY M (LPC)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:M
Last Name:SHAW
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 VERMONT ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3049
Mailing Address - Country:US
Mailing Address - Phone:217-222-8245
Mailing Address - Fax:217-222-4512
Practice Address - Street 1:915 VERMONT ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3049
Practice Address - Country:US
Practice Address - Phone:217-222-8245
Practice Address - Fax:217-222-4512
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0000132022OtherBLUE CROSS BLUE SHIELD