Provider Demographics
NPI:1285646166
Name:SHAW, EVELYN (MA)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2141 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6836
Mailing Address - Country:US
Mailing Address - Phone:325-949-9650
Mailing Address - Fax:325-949-9659
Practice Address - Street 1:2141 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6836
Practice Address - Country:US
Practice Address - Phone:325-949-9650
Practice Address - Fax:325-949-9659
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17409101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional