Provider Demographics
NPI:1578653887
Name:SHAW, ELLEN (MED ,LPC)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MED ,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-2810
Mailing Address - Country:US
Mailing Address - Phone:843-276-8906
Mailing Address - Fax:
Practice Address - Street 1:342 6TH AVE
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-2810
Practice Address - Country:US
Practice Address - Phone:843-276-8906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4233101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional