MEDICARE: SUSAN ANN SHAW LCSW

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	101YM0800X	Mental Health Counselor	490	WY

General Provider Information

NPI Number	:	1578657904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN ANN SHAW LCSW

Provider Business Mailing Address
First Line	:	501 SE 135
Second Line	:
City	:	LAWTON
State	:	OK
Zip	:	73501-3241
Country	:	US
Telephone Number	:	580-581-0273
Fax Number	:

Provider Business Practice Location Address
First Line	:	4301 MOW-WAY ROAD
Second Line	:	REYNOLDS ARMY COMMUNITY HOSPITAL
City	:	FORT SILL
State	:	OK
Zip	:	73505-6300
Country	:	US
Telephone Number	:	580-458-2134
Fax Number	:

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/08/2007

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