Provider Demographics
NPI:1679906879
Name:SHAW, SUSAN MARIE (LPC)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:SHAW
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6102 WESTDALE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8512
Mailing Address - Country:US
Mailing Address - Phone:810-813-2113
Mailing Address - Fax:
Practice Address - Street 1:127 NORTH RIVER STREET
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430
Practice Address - Country:US
Practice Address - Phone:810-309-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-12
Last Update Date:2024-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013785101Y00000X
MI6401224006101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor