Provider Demographics
NPI:1578055489
Name:SHAW, GWENDOLYN EARLENE (BA, MHS, LSW, CMHT)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:EARLENE
Last Name:SHAW
Suffix:
Gender:F
Credentials:BA, MHS, LSW, CMHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 HIGHWAY 7 S
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5392
Mailing Address - Country:US
Mailing Address - Phone:662-234-7521
Mailing Address - Fax:662-236-3071
Practice Address - Street 1:152 HIGHWAY 7 S
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:662-234-7521
Practice Address - Fax:662-236-3071
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool