Basic Information
| Provider Information | |||||||||
| NPI: | 1255722500 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | STACI | ||||||||
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| Credential: | LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 78 MAYFAIR RD | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449049781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2606686404 | ||||||||
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| Practice Location | |||||||||
| Address1: | 775 LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449071906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197744010 | ||||||||
| FaxNumber: | 4177744014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2015 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | S.1201024 | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | I.1500936-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.