Provider Demographics
NPI:1265025274
Name:WARTHEN, SHAVONNA S (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHAVONNA
Middle Name:S
Last Name:WARTHEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 HARBIN VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-2023
Mailing Address - Country:US
Mailing Address - Phone:404-394-9947
Mailing Address - Fax:
Practice Address - Street 1:2514 HARBIN VILLAGE CT
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2023
Practice Address - Country:US
Practice Address - Phone:404-394-9947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004221225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty