Provider Demographics
NPI:1861699563
Name:SHAW, KEVIN (LCSW, CADC III)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:LCSW, CADC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2577 NE COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-0000
Mailing Address - Country:US
Mailing Address - Phone:541-322-7500
Mailing Address - Fax:541-322-7565
Practice Address - Street 1:2577 NE COURTNEY DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7638
Practice Address - Country:US
Practice Address - Phone:541-322-7500
Practice Address - Fax:541-322-7565
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12-06-101U3101YA0400X
OR46581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)