MEDICARE: DEBRA SHAW MA,OTR/L

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	225XP0200X	Pediatric Occupational Therapist	03397	OH

General Provider Information

NPI Number	:	1740687425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBRA SHAW MA,OTR/L

Provider Business Mailing Address
First Line	:	5117 PICADOR RD SE
Second Line	:
City	:	CARROLLTON
State	:	OH
Zip	:	44615-8557
Country	:	US
Telephone Number	:	330-484-2547
Fax Number	:	330-484-3431

Provider Business Practice Location Address
First Line	:	3057 CLEVELAND AVE SW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44707-3625
Country	:	US
Telephone Number	:	330-484-2547
Fax Number	:	330-484-3431

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

Provider Enumeration Date	:	11/25/2014
Last Update Date	:	11/25/2014

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