Provider Demographics
NPI:1548546385
Name:SHAW WOOTEN, ERICA (PTA)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:SHAW WOOTEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:LATRISHA
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:PO BOX 24537
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4537
Mailing Address - Country:US
Mailing Address - Phone:877-554-4257
Mailing Address - Fax:601-983-2839
Practice Address - Street 1:2470 FLOWOOD DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9019
Practice Address - Country:US
Practice Address - Phone:877-554-4257
Practice Address - Fax:601-983-2839
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA4628225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant