Provider Demographics
NPI:1124441779
Name:SHAW, LELA
Entity type:Individual
Prefix:
First Name:LELA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5911 SOUTHSEAS ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77033-1911
Mailing Address - Country:US
Mailing Address - Phone:713-822-7815
Mailing Address - Fax:713-645-0014
Practice Address - Street 1:5911 SOUTHSEAS ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77033-1911
Practice Address - Country:US
Practice Address - Phone:713-822-7815
Practice Address - Fax:713-645-0014
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-31
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101Y00000X, 101YP2500X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1138315679OtherNIJ
TX1138754242OtherRTI