Provider Demographics
NPI:1154795680
Name:SHAW, SUSAN I (LCPC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SHAW
Suffix:I
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 LYDIA LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2156
Mailing Address - Country:US
Mailing Address - Phone:207-331-6102
Mailing Address - Fax:
Practice Address - Street 1:50 LYDIA LN
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2156
Practice Address - Country:US
Practice Address - Phone:207-331-6102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC4414101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health