Provider Demographics
NPI:1609471051
Name:SHAW, KRISTEN (LCSW)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:GREATHOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:
Practice Address - Street 1:1443 CORPORATE WAY
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-3391
Practice Address - Country:US
Practice Address - Phone:812-522-4341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34009064A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical