Provider Demographics
NPI:1508035429
Name:SHAW, EVELYN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:EVELYN
Middle Name:
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:PO BOX 917
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747
Mailing Address - Country:US
Mailing Address - Phone:732-619-0775
Mailing Address - Fax:
Practice Address - Street 1:10 PLAZA STREET EAST
Practice Address - Street 2:SUITE 1-C
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238
Practice Address - Country:US
Practice Address - Phone:212-561-1714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-25
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042751-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300197683Medicaid