Provider Demographics
NPI:1124787510
Name:SHAW, LACEY R
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:R
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 1:7500 SAN FELIPE ST STE 990
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-1708
Mailing Address - Country:US
Mailing Address - Phone:281-826-3382
Mailing Address - Fax:425-491-7683
Practice Address - Street 1:10 ARBORLAND WAY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-2201
Practice Address - Country:US
Practice Address - Phone:864-520-1614
Practice Address - Fax:864-484-8458
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
1-22-59042103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician