Provider Demographics
NPI:1578657904
Name:SHAW, SUSAN ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
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 1:501 SE 135
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-3241
Mailing Address - Country:US
Mailing Address - Phone:580-581-0273
Mailing Address - Fax:
Practice Address - Street 1:4301 MOW-WAY ROAD
Practice Address - Street 2:REYNOLDS ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73505-6300
Practice Address - Country:US
Practice Address - Phone:580-458-2134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY490101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health