Basic Information
Provider Information | |||||||||
NPI: | 1659321503 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHAW | ||||||||
FirstName: | RENEE | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JOE | ||||||||
OtherFirstName: | RENEE | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1278 N LAFAYETTE DR | ||||||||
Address2: |   | ||||||||
City: | SUMTER | ||||||||
State: | SC | ||||||||
PostalCode: | 291502964 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037744500 | ||||||||
FaxNumber: | 8037744641 | ||||||||
Practice Location | |||||||||
Address1: | 1278 N LAFAYETTE DR | ||||||||
Address2: |   | ||||||||
City: | SUMTER | ||||||||
State: | SC | ||||||||
PostalCode: | 291502964 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037744500 | ||||||||
FaxNumber: | 8037744641 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2006 | ||||||||
LastUpdateDate: | 10/25/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 5315 | SC | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 372048 | 05 | SC |   | MEDICAID |