Provider Demographics
NPI:1386797280
Name:SHAW, ROBERTA E (LCPC)
Entity type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:E
Last Name:SHAW
Suffix:
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 1:12 DAMASCUS RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04937-4307
Mailing Address - Country:US
Mailing Address - Phone:207-453-7980
Mailing Address - Fax:207-649-8384
Practice Address - Street 1:12 DAMASCUS RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:ME
Practice Address - Zip Code:04937-4307
Practice Address - Country:US
Practice Address - Phone:207-453-7980
Practice Address - Fax:207-649-8384
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC987101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME128320000Medicaid