Provider Demographics
NPI:1255593240
Name:SHAW, KATHRYN MARY (PHD, DC)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:MARY
Last Name:SHAW
Suffix:
Gender:F
Credentials:PHD, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3773 FIANO DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-8623
Mailing Address - Country:US
Mailing Address - Phone:407-421-4554
Mailing Address - Fax:
Practice Address - Street 1:3773 FIANO DR
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-8623
Practice Address - Country:US
Practice Address - Phone:407-421-4554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9554111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000854600Medicaid
FL88959OtherBCBS
FL000854600Medicaid