Provider Demographics
NPI:1215178926
Name:SHAW, MARTIN K (LPC, LMFT)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:K
Last Name:SHAW
Suffix:
Gender:M
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4812 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-5312
Mailing Address - Country:US
Mailing Address - Phone:940-432-8631
Mailing Address - Fax:
Practice Address - Street 1:12650 N BEACH ST STE 114
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-4245
Practice Address - Country:US
Practice Address - Phone:940-432-8631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-11
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63283101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200595102Medicaid
TX200595101Medicaid