Provider Demographics
NPI:1376277103
Name:GEATHERS, SHAQUANDA SIMONE (MT)
Entity Type:Individual
Prefix:
First Name:SHAQUANDA
Middle Name:SIMONE
Last Name:GEATHERS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5846 MONROE RD APT E1
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-6120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9711 DAVID TAYLOR DR APT 218
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-2375
Practice Address - Country:US
Practice Address - Phone:980-888-3129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15468225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist