Provider Demographics
NPI:1346721024
Name:SHADE, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SHADE
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 1:812 E WARD DR
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:TX
Mailing Address - Zip Code:76706-5924
Mailing Address - Country:US
Mailing Address - Phone:254-214-3341
Mailing Address - Fax:
Practice Address - Street 1:812 E WARD DR
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:TX
Practice Address - Zip Code:76706-5924
Practice Address - Country:US
Practice Address - Phone:254-214-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110937225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist