Provider Demographics
NPI:1770652224
Name:SHAW, FRREDERICK GARDINER (MS, LCPC)
Entity Type:Individual
Prefix:
First Name:FRREDERICK
Middle Name:GARDINER
Last Name:SHAW
Suffix:
Gender:M
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 BENNETT LN
Mailing Address - Street 2:
Mailing Address - City:COBDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62920-3223
Mailing Address - Country:US
Mailing Address - Phone:618-893-6115
Mailing Address - Fax:
Practice Address - Street 1:6655 E. US 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IL
Practice Address - Zip Code:46123
Practice Address - Country:US
Practice Address - Phone:317-272-3330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9132002OtherBLUE CROSS BLUE SHIELD
IL073120OtherHEALTH ALLIANCE