Provider Demographics
NPI:1356782791
Name:SHAW, MICHAEL JAY (MS, LPC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAY
Last Name:SHAW
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:TX
Mailing Address - Zip Code:76055-0131
Mailing Address - Country:US
Mailing Address - Phone:214-724-0702
Mailing Address - Fax:214-245-5918
Practice Address - Street 1:3900 BLUEBONNET LN
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:TX
Practice Address - Zip Code:76670-1259
Practice Address - Country:US
Practice Address - Phone:214-724-0702
Practice Address - Fax:214-245-5918
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68698101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional