Provider Demographics
NPI:1902159411
Name:SHAW, BRANDI NICOLE (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:BRANDI
Middle Name:NICOLE
Last Name:SHAW
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 KINGSTON WAY
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29625-5230
Mailing Address - Country:US
Mailing Address - Phone:864-224-8076
Mailing Address - Fax:
Practice Address - Street 1:1306 PELHAM RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3600
Practice Address - Country:US
Practice Address - Phone:864-933-3050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4025225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist