Provider Demographics
NPI:1134477573
Name:SHAW, KATHLEEN CONNIE (LLMSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:CONNIE
Last Name:SHAW
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34367 VIRGIL ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-3387
Mailing Address - Country:US
Mailing Address - Phone:586-822-1298
Mailing Address - Fax:
Practice Address - Street 1:34367 VIRGIL ST
Practice Address - Street 2:
Practice Address - City:HARRISON TWP
Practice Address - State:MI
Practice Address - Zip Code:48045-3387
Practice Address - Country:US
Practice Address - Phone:586-822-1298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI30799751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical