Provider Demographics
NPI:1700445491
Name:SHAW, MELISSA CHARLENE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:CHARLENE
Last Name:SHAW
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1071 MCFARLAND ST
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-3526
Mailing Address - Country:US
Mailing Address - Phone:727-437-7505
Mailing Address - Fax:
Practice Address - Street 1:499 ALT KEENE RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-1652
Practice Address - Country:US
Practice Address - Phone:727-437-1623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21670225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant