Provider Demographics
NPI:1639409360
Name:KINSELLA-SHAW, MARY (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KINSELLA-SHAW
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 STORRS RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1683
Mailing Address - Country:US
Mailing Address - Phone:860-456-1311
Mailing Address - Fax:860-456-0164
Practice Address - Street 1:189 STORRS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1683
Practice Address - Country:US
Practice Address - Phone:860-456-1311
Practice Address - Fax:860-456-0164
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000168101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional