Provider Demographics
NPI:1215178926
Name:SHAW, MARTIN K (LPC)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:K
Last Name:SHAW
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4219
Mailing Address - Country:US
Mailing Address - Phone:940-322-9456
Mailing Address - Fax:940-322-6759
Practice Address - Street 1:1808 ROSE ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4219
Practice Address - Country:US
Practice Address - Phone:940-723-4488
Practice Address - Fax:940-723-4490
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-11
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63283101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200595102Medicaid
TX200595101Medicaid