Provider Demographics
NPI:1972860757
Name:SHAW, MACKENZIE (LPC INTERN)
Entity Type:Individual
Prefix:MRS
First Name:MACKENZIE
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:LPC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 VIRGINIA PL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-3976
Mailing Address - Country:US
Mailing Address - Phone:817-343-4226
Mailing Address - Fax:
Practice Address - Street 1:207 W HICKORY ST STE 106
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-4147
Practice Address - Country:US
Practice Address - Phone:972-523-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67022101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional