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General NPI Number Information
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NPI Number | 1215178926
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Entity Type | Individual
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Provider Name | MARTIN K SHAW LPC, LMFT
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Gender | Male
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Dates
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Enumeration Date | 03/11/2009
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Last Update Date | 06/27/2024
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Provider Practice Location Address
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Address Line | 12650 N BEACH ST STE 114
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City | FORT WORTH
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State | TX
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Zip | 76244-4245
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Country | US
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Telephone | 940-432-8631
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Fax |
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Provider Business Mailing Address
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Address Line | 4812 MAPLEWOOD AVE
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City | WICHITA FALLS
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State | TX
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Zip | 76308-5312
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Country | US
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Telephone | 940-432-8631
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 63283
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License Number State | TX
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