Provider Demographics
NPI:1699809194
Name:SHAW, RENEE D (MA)
Entity Type:Individual
Prefix:MS
First Name:RENEE
Middle Name:D
Last Name:SHAW
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1343 SABRA RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-2157
Mailing Address - Country:US
Mailing Address - Phone:419-476-5139
Mailing Address - Fax:
Practice Address - Street 1:SALVATION ARMY HARBOR LIGHT
Practice Address - Street 2:25 S MONROE ST SUITE 309
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161
Practice Address - Country:US
Practice Address - Phone:734-457-4340
Practice Address - Fax:734-230-0033
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005504101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)