MEDICARE: MS. DESIREE M SHAW PT, MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	3711	CO
2	225100000X	Physical Therapist	3393	CO

General Provider Information

NPI Number	:	1497758403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DESIREE M SHAW PT, MPT

Provider Business Mailing Address
First Line	:	4674 SNOW MESA DR
Second Line	:	SUITE 140
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-8615
Country	:	US
Telephone Number	:	970-266-3850
Fax Number	:	970-266-3855

Provider Business Practice Location Address
First Line	:	4674 SNOW MESA DR
Second Line	:	SUITE 140
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-8615
Country	:	US
Telephone Number	:	970-266-3850
Fax Number	:	970-266-3855

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	07/21/2008

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