Provider Demographics
NPI:1912098278
Name:SHAW, ROBERT T (LPC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:T
Last Name:SHAW
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2528 GREGERSON DR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-9680
Mailing Address - Country:US
Mailing Address - Phone:715-828-6462
Mailing Address - Fax:715-953-2020
Practice Address - Street 1:2528 GREGERSON DR
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-9680
Practice Address - Country:US
Practice Address - Phone:715-828-6462
Practice Address - Fax:715-953-2020
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI511-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1912098278Medicaid