Provider Demographics
NPI:1902059702
Name:SHAW, LORI ANN (LMT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:SHAW
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 JEFFERSON CT
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:ME
Mailing Address - Zip Code:04055-5044
Mailing Address - Country:US
Mailing Address - Phone:207-632-3189
Mailing Address - Fax:
Practice Address - Street 1:5 S CASCO VILLAGE RD
Practice Address - Street 2:
Practice Address - City:CASCO
Practice Address - State:ME
Practice Address - Zip Code:04015-4246
Practice Address - Country:US
Practice Address - Phone:207-655-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT2492225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME200719OtherANTHEM PROVIDER #