Provider Demographics
NPI:1659416626
Name:SHAW, MICHAEL M (PHD, LMHC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:M
Last Name:SHAW
Suffix:
Gender:M
Credentials:PHD, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2457 CLUBSIDE CT APT 215
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-1752
Mailing Address - Country:US
Mailing Address - Phone:727-943-8918
Mailing Address - Fax:
Practice Address - Street 1:2425 CHATLIN ROAD
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34691
Practice Address - Country:US
Practice Address - Phone:727-943-4847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 8792101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional