Provider Demographics
NPI:1578780912
Name:SHAW, CARRIE BETH (LPC)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:BETH
Last Name:SHAW
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 COUNTRY PL
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7407
Mailing Address - Country:US
Mailing Address - Phone:903-238-6924
Mailing Address - Fax:903-663-5435
Practice Address - Street 1:208 PINE TREE RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-4104
Practice Address - Country:US
Practice Address - Phone:903-235-5862
Practice Address - Fax:903-295-3094
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16092101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177591801Medicaid