Provider Demographics
NPI:1982887725
Name:SHAW, CANDICE VASQUEZ (MSPT)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:VASQUEZ
Last Name:SHAW
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:ANN
Other - Last Name:VASQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:13537 BARRETT PARKWAY DRIVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-5896
Mailing Address - Country:US
Mailing Address - Phone:314-821-9126
Mailing Address - Fax:314-821-9142
Practice Address - Street 1:107 CONCORD PLAZA
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-1307
Practice Address - Country:US
Practice Address - Phone:314-842-2990
Practice Address - Fax:314-842-5162
Is Sole Proprietor?:No
Enumeration Date:2007-12-16
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007028657225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist