Provider Demographics
NPI:1881896272
Name:SHAW, TERESA LYNN (OTR L)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:SHAW
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:LYNN
Other - Last Name:HEIMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR L
Mailing Address - Street 1:1716 ARLINGTON AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-1507
Mailing Address - Country:US
Mailing Address - Phone:651-776-2291
Mailing Address - Fax:
Practice Address - Street 1:2705 ENLOE ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8173
Practice Address - Country:US
Practice Address - Phone:715-386-2128
Practice Address - Fax:715-386-6119
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4235225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40445000Medicaid
6405180OtherMEDICA
HP47973OtherHEALTH PARTNERS
641671046996OtherPREFERRED ONE
MN98G79SHOtherBCBS MN