Provider Demographics
NPI:1164891032
Name:SHIMOTA, KAITLIN (ATC)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:SHIMOTA
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:BUTTS-MEHRE HERITAGE HALL
Mailing Address - Street 2:1 SELIG CIRCLE
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30602
Mailing Address - Country:US
Mailing Address - Phone:706-542-6521
Mailing Address - Fax:
Practice Address - Street 1:STEGEMAN COLISEUM
Practice Address - Street 2:100 SMITH STREET
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30602-0001
Practice Address - Country:US
Practice Address - Phone:706-542-6521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0024802255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer