Provider Demographics
NPI:1295392819
Name:SHAW, MICHELLE NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
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 1:430 NIAGARA ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14201-1886
Mailing Address - Country:US
Mailing Address - Phone:716-853-1335
Mailing Address - Fax:716-853-1598
Practice Address - Street 1:790 RIDGE RD
Practice Address - Street 2:
Practice Address - City:LACKAWANNA
Practice Address - State:NY
Practice Address - Zip Code:14218-1629
Practice Address - Country:US
Practice Address - Phone:716-828-9651
Practice Address - Fax:716-828-9450
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0957131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical