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General NPI Number Information
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NPI Number | 1083253520
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Entity Type | Individual
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Provider Name | SHAKA D MCCORMICK LMT
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Gender | Female
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Dates
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Enumeration Date | 01/01/2020
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Last Update Date | 01/01/2020
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Provider Practice Location Address
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Address Line | 2804 OSAGE ST
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City | SAINT LOUIS
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State | MO
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Zip | 63118-4537
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Country | US
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Telephone | 314-448-0143
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 27041
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City | SAINT LOUIS
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State | MO
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Zip | 63118-0041
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Country | US
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Telephone | 618-918-1245
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 2019000899
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License Number State | MO
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