Provider Demographics
NPI:1922714971
Name:SHAW, MARILYN (LMSW-T)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:LMSW-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 N ROCK RD STE 405
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-1354
Mailing Address - Country:US
Mailing Address - Phone:316-779-8185
Mailing Address - Fax:
Practice Address - Street 1:3450 N ROCK RD STE 405
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-1354
Practice Address - Country:US
Practice Address - Phone:316-779-8185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12966-T104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS12966-TOtherBCBS
KS12966-TMedicaid