Provider Demographics
NPI:1225795859
Name:SHAW, SUSAN L (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:SHAW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12391 HIGHWAY 491 S
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:MS
Mailing Address - Zip Code:39365-8538
Mailing Address - Country:US
Mailing Address - Phone:601-513-2476
Mailing Address - Fax:
Practice Address - Street 1:1205 22ND AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4010
Practice Address - Country:US
Practice Address - Phone:601-483-2864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC64471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical