Provider Demographics
NPI:1053702852
Name:SHAW, BROOKE (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3879 BILL JONES RD
Mailing Address - Street 2:
Mailing Address - City:APISON
Mailing Address - State:TN
Mailing Address - Zip Code:37302-9749
Mailing Address - Country:US
Mailing Address - Phone:423-322-5487
Mailing Address - Fax:
Practice Address - Street 1:2222 SULLIVAN TRL
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18040-7958
Practice Address - Country:US
Practice Address - Phone:610-991-2034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-15
Last Update Date:2015-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOTA0000001752261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation