Healthcare Provider Details

I. General information

NPI: 1144718552
Provider Name (Legal Business Name): MELISSA MCKENZY-SHAW LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 N MAIN ST
LAS CRUCES NM
88001-1102
US

IV. Provider business mailing address

314 PHILLIPS DR
LAS CRUCES NM
88005-1661
US

V. Phone/Fax

Practice location:
  • Phone: 575-449-6504
  • Fax:
Mailing address:
  • Phone: 575-449-6504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8894
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: