Provider Demographics
NPI:1922346253
Name:SHAW, REBECCA (LPC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 E PONCE DE LEON AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2512
Mailing Address - Country:US
Mailing Address - Phone:678-595-0036
Mailing Address - Fax:
Practice Address - Street 1:108 E PONCE DE LEON AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2512
Practice Address - Country:US
Practice Address - Phone:678-595-0036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC002857101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional