Provider Demographics
NPI:1508015843
Name:BLACK SOUTHALL, SHANELL L (OT)
Entity Type:Individual
Prefix:
First Name:SHANELL
Middle Name:L
Last Name:BLACK SOUTHALL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9303 PRESTON RUN
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-1942
Mailing Address - Country:US
Mailing Address - Phone:615-260-2978
Mailing Address - Fax:
Practice Address - Street 1:9303 PRESTON RUN
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-1942
Practice Address - Country:US
Practice Address - Phone:615-260-2978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5565225700000X
TN3691225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist