Provider Demographics
NPI:1740611367
Name:SHAW, VICTORIA (PHD, LPC)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 STURGES HOLW
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-2851
Mailing Address - Country:US
Mailing Address - Phone:203-254-3403
Mailing Address - Fax:203-254-3403
Practice Address - Street 1:3 HOLLYHOCK RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-4443
Practice Address - Country:US
Practice Address - Phone:203-254-3403
Practice Address - Fax:203-254-3403
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-07
Last Update Date:2013-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002408101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional