Healthcare Provider Details

I. General information

NPI: 1053720482
Provider Name (Legal Business Name): ELLEN SHAW PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 12/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 N EVERGREEN RD STE 10
SPOKANE VALLEY WA
99216-1485
US

IV. Provider business mailing address

16083 SW UPPER BOONES FERRY RD STE 300
TIGARD OR
97224-7736
US

V. Phone/Fax

Practice location:
  • Phone: 509-926-5367
  • Fax: 509-928-5508
Mailing address:
  • Phone: 800-219-8835
  • Fax: 503-639-9699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number60462884
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: