Provider Demographics
NPI:1790026508
Name:SHADWICK, LEAH (LAC)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:SHADWICK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 MEDICAL PKWY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3734
Mailing Address - Country:US
Mailing Address - Phone:512-761-6719
Mailing Address - Fax:
Practice Address - Street 1:4101 MEDICAL PKWY
Practice Address - Street 2:SUITE 204
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3734
Practice Address - Country:US
Practice Address - Phone:512-761-6719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01379171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist