Provider Demographics
NPI:1386185460
Name:PORTEE, SHARDAE
Entity Type:Individual
Prefix:
First Name:SHARDAE
Middle Name:
Last Name:PORTEE
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 1:6250 RIVERVIEW RD SE APT 2116
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2979
Mailing Address - Country:US
Mailing Address - Phone:803-372-7151
Mailing Address - Fax:
Practice Address - Street 1:966A KILLIAN HILL RD SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3102
Practice Address - Country:US
Practice Address - Phone:770-923-4815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006777225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand