Provider Demographics
NPI:1003537556
Name:OFERRELL, DELISHA DANIEAL (ATC)
Entity Type:Individual
Prefix:
First Name:DELISHA
Middle Name:DANIEAL
Last Name:OFERRELL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3570 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-1893
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3570 WHEELER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1893
Practice Address - Country:US
Practice Address - Phone:706-922-9627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT001424405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional