Basic Information
| Provider Information | |||||||||
| NPI: | 1922664432 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | WELLS | ||||||||
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| NameSuffix: | V | ||||||||
| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33 LEWIS RD | ||||||||
| Address2: | 2ND FL | ||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077298156 | ||||||||
| FaxNumber: | 6077293982 | ||||||||
| Practice Location | |||||||||
| Address1: | 10-42 MITCHELL AVE | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139031617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077622990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2019 | ||||||||
| LastUpdateDate: | 05/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 104892 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.