Provider Demographics
NPI:1255722500
Name:SHAW, STACI (LISW-S)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44904-9781
Mailing Address - Country:US
Mailing Address - Phone:260-668-6404
Mailing Address - Fax:
Practice Address - Street 1:775 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-1906
Practice Address - Country:US
Practice Address - Phone:419-774-4010
Practice Address - Fax:417-774-4014
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1201024101YM0800X
OHI.1500936-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health