Provider Demographics
NPI:1861968687
Name:SHAW, LYNDE (PTA)
Entity type:Individual
Prefix:
First Name:LYNDE
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-1498
Mailing Address - Country:US
Mailing Address - Phone:614-915-2112
Mailing Address - Fax:
Practice Address - Street 1:3802 TURKEYFOOT RD
Practice Address - Street 2:
Practice Address - City:ELSMERE
Practice Address - State:KY
Practice Address - Zip Code:41018-2838
Practice Address - Country:US
Practice Address - Phone:859-342-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA03890225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty