MEDICARE: MR. MARTIN K SHAW LPC, LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	63283	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215178926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARTIN K SHAW LPC, LMFT

Provider Business Mailing Address
First Line	:	4812 MAPLEWOOD AVE
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76308-5312
Country	:	US
Telephone Number	:	940-432-8631
Fax Number	:

Provider Business Practice Location Address
First Line	:	12650 N BEACH ST STE 114
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4245
Country	:	US
Telephone Number	:	940-432-8631
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2009
Last Update Date	:	06/27/2024

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