Provider Demographics
NPI:1083070155
Name:SHAW, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SHAW
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8460 RADNOR RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23503-4053
Mailing Address - Country:US
Mailing Address - Phone:508-314-3820
Mailing Address - Fax:
Practice Address - Street 1:5604 VIRGINIA BEACH BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5631
Practice Address - Country:US
Practice Address - Phone:508-314-3820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004603225X00000X
VA0119010762225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist