Provider Demographics
NPI:1033302849
Name:SHAW, KATHLEEN ANNE (LMT)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANNE
Last Name:SHAW
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8879 NW 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-6167
Mailing Address - Country:US
Mailing Address - Phone:954-815-0666
Mailing Address - Fax:
Practice Address - Street 1:7866 W SAMPLE RD
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33065-4710
Practice Address - Country:US
Practice Address - Phone:954-341-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA21129225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist