Provider Demographics
NPI:1548935380
Name:SHAW, CARMALETA L (PHD)
Entity type:Individual
Prefix:MS
First Name:CARMALETA
Middle Name:L
Last Name:SHAW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:CARMALETA
Other - Middle Name:L
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 274
Mailing Address - Street 2:
Mailing Address - City:SHAW
Mailing Address - State:MS
Mailing Address - Zip Code:38773-0274
Mailing Address - Country:US
Mailing Address - Phone:662-374-9794
Mailing Address - Fax:
Practice Address - Street 1:103 SCOTT STREET
Practice Address - Street 2:
Practice Address - City:SHAW
Practice Address - State:MS
Practice Address - Zip Code:38773-3877
Practice Address - Country:US
Practice Address - Phone:662-374-9794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS163762101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool