Provider Demographics
NPI:1184014250
Name:SHAW, RANDALL (MHS, LRT/CTRS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:MHS, LRT/CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 802
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28802-0802
Mailing Address - Country:US
Mailing Address - Phone:828-277-1315
Mailing Address - Fax:828-277-1321
Practice Address - Street 1:121 SHILOH RD
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-1626
Practice Address - Country:US
Practice Address - Phone:828-277-1315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1448225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist