Provider Demographics
NPI:1619902160
Name:SHAW, GWEN (MSSW LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MSSW LCSW
Other - Prefix:MRS
Other - First Name:GWEN
Other - Middle Name:E
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3515 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1307
Mailing Address - Country:US
Mailing Address - Phone:806-799-8830
Mailing Address - Fax:806-799-4688
Practice Address - Street 1:3515 22ND ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1307
Practice Address - Country:US
Practice Address - Phone:806-799-8830
Practice Address - Fax:806-799-4688
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX002503106H00000X
TX4952101YA0400X
TX009891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX119740203Medicaid
TX119740203Medicaid
TXS00989Medicare UPIN
TXTX00989Medicare UPIN