Provider Demographics
NPI:1659321503
Name:SHAW, RENEE MICHELLE
Entity Type:Individual
Prefix:MS
First Name:RENEE
Middle Name:MICHELLE
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:RENEE
Other - Middle Name:M
Other - Last Name:JOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1278 N LAFAYETTE DR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-2964
Mailing Address - Country:US
Mailing Address - Phone:803-774-4500
Mailing Address - Fax:803-774-4641
Practice Address - Street 1:1278 N LAFAYETTE DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2964
Practice Address - Country:US
Practice Address - Phone:803-774-4500
Practice Address - Fax:803-774-4641
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5315101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC372048Medicaid