Provider Demographics
NPI:1427279728
Name:SHAW, MIMI MARY (OT)
Entity type:Individual
Prefix:
First Name:MIMI
Middle Name:MARY
Last Name:SHAW
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 S HARVARD CT
Mailing Address - Street 2:APT 27A
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-4626
Mailing Address - Country:US
Mailing Address - Phone:918-748-4417
Mailing Address - Fax:
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-474-1474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1029225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist