Provider Demographics
NPI:1225809221
Name:MCLEOD, SHAKYLA LAQUESHA
Entity Type:Individual
Prefix:
First Name:SHAKYLA
Middle Name:LAQUESHA
Last Name:MCLEOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 GREAT FLS
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5813
Mailing Address - Country:US
Mailing Address - Phone:706-564-4209
Mailing Address - Fax:
Practice Address - Street 1:544 GREAT FLS
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-5813
Practice Address - Country:US
Practice Address - Phone:706-564-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT014075225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist