MEDICARE: COLLEEN SHAW

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	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1659763910
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN SHAW

Provider Business Mailing Address
First Line	:	10111 N CANTERBURY RD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19114-1113
Country	:	US
Telephone Number	:	267-230-8312
Fax Number	:

Provider Business Practice Location Address
First Line	:	10111 N CANTERBURY RD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19114-1113
Country	:	US
Telephone Number	:	267-230-8312
Fax Number	:

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

Provider Enumeration Date	:	02/24/2015
Last Update Date	:	02/24/2015

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Directions to “ COLLEEN SHAW ” Practice Location

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