Provider Demographics
NPI:1962068650
Name:SHAW, KELLY GRACE (MS, LPC, NCC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:GRACE
Last Name:SHAW
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18
Mailing Address - Street 2:
Mailing Address - City:VIDA
Mailing Address - State:OR
Mailing Address - Zip Code:97488-0018
Mailing Address - Country:US
Mailing Address - Phone:541-771-1017
Mailing Address - Fax:
Practice Address - Street 1:770 E 11TH AVE FL SSB2
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3746
Practice Address - Country:US
Practice Address - Phone:458-205-7085
Practice Address - Fax:458-205-7089
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor