Provider Demographics
NPI:1497075998
Name:SHAW, KELLIE
Entity type:Individual
Prefix:MISS
First Name:KELLIE
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1785 S HAYES ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22202-2714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1785 S HAYES ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22202-2714
Practice Address - Country:US
Practice Address - Phone:703-685-3000
Practice Address - Fax:703-625-0741
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602846225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant