Provider Demographics
NPI:1376723874
Name:SHAW, KELLY ANNE (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANNE
Last Name:SHAW
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:89 TRONSTAD DR
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-6883
Mailing Address - Country:US
Mailing Address - Phone:406-212-0990
Mailing Address - Fax:
Practice Address - Street 1:200 HERITAGE WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3146
Practice Address - Country:US
Practice Address - Phone:406-752-1760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1053101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional