Provider Demographics
NPI:1780231100
Name:SHAW, KELLY GRACE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:GRACE
Last Name:SHAW
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:757 WHITNEYS LANDING DR
Mailing Address - Street 2:
Mailing Address - City:CROWNSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21032-1113
Mailing Address - Country:US
Mailing Address - Phone:443-789-4440
Mailing Address - Fax:
Practice Address - Street 1:757 WHITNEYS LANDING DR
Practice Address - Street 2:
Practice Address - City:CROWNSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21032-1113
Practice Address - Country:US
Practice Address - Phone:443-420-8073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD277181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical