Provider Demographics
NPI:1164780615
Name:DEGRAW, SHANIN LEAH (PTA)
Entity Type:Individual
Prefix:MS
First Name:SHANIN
Middle Name:LEAH
Last Name:DEGRAW
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27307 CONNER RD
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:FL
Mailing Address - Zip Code:32046
Mailing Address - Country:US
Mailing Address - Phone:904-237-9391
Mailing Address - Fax:
Practice Address - Street 1:1885 S 14TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3033
Practice Address - Country:US
Practice Address - Phone:904-277-4449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22943174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist