Individual
FRREDERICK GARDINER SHAW
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MS, LCPC
Contact information
Practice address
6655 E. US 36, AVON, IL 46123
(317) 272-3330
Mailing address
575 BENNETT LN, COBDEN, IL 62920-3223
(618) 893-6115
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
073120
HEALTH ALLIANCE
IL
01
—
9132002
BLUE CROSS BLUE SHIELD
IL
Enumeration date
11/07/2006
Last updated
07/08/2007
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