Provider Demographics
NPI:1730791609
Name:SHAW, TONY C (LCPC)
Entity type:Individual
Prefix:MR
First Name:TONY
Middle Name:C
Last Name:SHAW
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:MR
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:2814 W GARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5335
Mailing Address - Country:US
Mailing Address - Phone:443-629-5155
Mailing Address - Fax:
Practice Address - Street 1:102 6TH AVE NE STE B
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21060-6869
Practice Address - Country:US
Practice Address - Phone:410-352-7514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC11938101YA0400X, 101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)