Provider Demographics
NPI:1689027039
Name:SHAW, TIFFANY (LAT, CPHT)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:LAT, CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 GOLFERS WAY
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-3061
Mailing Address - Country:US
Mailing Address - Phone:817-694-7900
Mailing Address - Fax:
Practice Address - Street 1:1200 BOYD RD
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-2522
Practice Address - Country:US
Practice Address - Phone:817-444-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT39812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer