Provider Demographics
NPI:1417139007
Name:SHAW, KIMBERLY DAWN (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:SHAW
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DAWN
Other - Last Name:NEWMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:15413 S CR 207
Mailing Address - Street 2:
Mailing Address - City:BLAIR
Mailing Address - State:OK
Mailing Address - Zip Code:73526-9256
Mailing Address - Country:US
Mailing Address - Phone:580-301-4277
Mailing Address - Fax:
Practice Address - Street 1:811 E VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-7919
Practice Address - Country:US
Practice Address - Phone:405-377-8255
Practice Address - Fax:405-835-3920
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK952224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant