Provider Demographics
NPI:1093347916
Name:SHAW, LESLIE M
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 CAVALIER BLVD STE 222
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-3959
Mailing Address - Country:US
Mailing Address - Phone:407-212-5814
Mailing Address - Fax:
Practice Address - Street 1:75 CAVALIER BLVD STE 222
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-3959
Practice Address - Country:US
Practice Address - Phone:407-212-5814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-08
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY107614225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist