Provider Demographics
NPI:1639193105
Name:SHAW, KEVIN B (LCP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:B
Last Name:SHAW
Suffix:
Gender:M
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1953 RENO RD
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:KS
Mailing Address - Zip Code:66067-8754
Mailing Address - Country:US
Mailing Address - Phone:785-242-8059
Mailing Address - Fax:
Practice Address - Street 1:109 W 2ND ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:KS
Practice Address - Zip Code:66067-2212
Practice Address - Country:US
Practice Address - Phone:785-242-2991
Practice Address - Fax:785-242-4401
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS------101YA0400X
KS065103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)