Provider Demographics
NPI:1477080927
Name:SHAW, KATHLEEN MARIE (PLPC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:SHAW
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 RUSTY RD LOT 18
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-8427
Mailing Address - Country:US
Mailing Address - Phone:337-277-0532
Mailing Address - Fax:337-237-2083
Practice Address - Street 1:611 W ADMIRAL DOYLE DR
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-6408
Practice Address - Country:US
Practice Address - Phone:337-373-0002
Practice Address - Fax:337-373-0129
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6700101YM0800X
171M00000X
LAPLC6700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator