Provider Demographics
NPI:1952065690
Name:SHAW, COLEEN JOAN (COTA/L)
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:JOAN
Last Name:SHAW
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SOUTHWICK RD
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-4230
Mailing Address - Country:US
Mailing Address - Phone:978-766-0045
Mailing Address - Fax:
Practice Address - Street 1:500 CUMMINGS CTR STE 3850
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6509
Practice Address - Country:US
Practice Address - Phone:978-232-0332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2916224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant