Provider Demographics
NPI:1376279745
Name:CANNON, SHELBY CHRISTINE (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:CHRISTINE
Last Name:CANNON
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 1:1100 HAMPSTEAD PL
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-6202
Mailing Address - Country:US
Mailing Address - Phone:706-339-2132
Mailing Address - Fax:
Practice Address - Street 1:536 GRAND SLAM DR STE D
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-8045
Practice Address - Country:US
Practice Address - Phone:706-854-8434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT008551225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist