Provider Demographics
NPI:1023160538
Name:SHAW, SUSAN (MSW, LICSW, LADC-1)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MSW, LICSW, LADC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 440189
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-0002
Mailing Address - Country:US
Mailing Address - Phone:617-224-3107
Mailing Address - Fax:
Practice Address - Street 1:299 BROADWAY
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02474
Practice Address - Country:US
Practice Address - Phone:617-224-3107
Practice Address - Fax:617-623-3653
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1626101YA0400X
MA10321751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MASH P22373Medicare ID - Type Unspecified