Provider Demographics
NPI:1922543339
Name:SHAW, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
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 1:196 FORD ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-3043
Mailing Address - Country:US
Mailing Address - Phone:313-300-5362
Mailing Address - Fax:
Practice Address - Street 1:23077 GREENFIELD RD STE 250
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3768
Practice Address - Country:US
Practice Address - Phone:313-300-5362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-21
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501002362225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist