Provider Demographics
NPI:1487989349
Name:SHAW, HEATHER DENISE
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:DENISE
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N BRIARCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-2959
Mailing Address - Country:US
Mailing Address - Phone:920-739-4466
Mailing Address - Fax:
Practice Address - Street 1:601 N BRIARCLIFF DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-2959
Practice Address - Country:US
Practice Address - Phone:920-739-4466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-12
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI536019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI56019Medicaid