Provider Demographics
NPI:1578286019
Name:SHAW, LAUREN MARINA (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MARINA
Last Name:SHAW
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 GAIL BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-5717
Mailing Address - Country:US
Mailing Address - Phone:808-634-9641
Mailing Address - Fax:
Practice Address - Street 1:4504 GAIL BLVD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-5717
Practice Address - Country:US
Practice Address - Phone:808-634-9641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA99114225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist