Provider Demographics
NPI:1154441863
Name:SHAW, EARL MERRILL (LSAC)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:MERRILL
Last Name:SHAW
Suffix:
Gender:F
Credentials:LSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:UT
Mailing Address - Zip Code:84647-1331
Mailing Address - Country:US
Mailing Address - Phone:435-462-2416
Mailing Address - Fax:435-462-9350
Practice Address - Street 1:656 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-1123
Practice Address - Country:US
Practice Address - Phone:435-623-1456
Practice Address - Fax:435-623-1127
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT349732-6006101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor