Provider Demographics
NPI:1225003684
Name:SHAW, BETHANY ALTA (ATC, LAT)
Entity type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:ALTA
Last Name:SHAW
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 E CAPITOL DR
Mailing Address - Street 2:#212
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-1951
Mailing Address - Country:US
Mailing Address - Phone:414-234-6130
Mailing Address - Fax:
Practice Address - Street 1:2025 E NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-2906
Practice Address - Country:US
Practice Address - Phone:414-961-4666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI693-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer