Provider Demographics
NPI:1629176938
Name:SHAW, LISA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 W MASON ST STE 102
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2049
Mailing Address - Country:US
Mailing Address - Phone:920-301-3546
Mailing Address - Fax:920-301-3400
Practice Address - Street 1:1345 W MASON ST STE 102
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2049
Practice Address - Country:US
Practice Address - Phone:920-301-3546
Practice Address - Fax:920-301-3400
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7747-1231041C0700X
WI126696-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43086600Medicaid