Provider Demographics
NPI:1578571865
Name:MATTINGLY, SHANNON MICHELLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:MATTINGLY
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 1:109 FLEETWOOD DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-2019
Mailing Address - Country:US
Mailing Address - Phone:864-855-7030
Mailing Address - Fax:864-855-7019
Practice Address - Street 1:790 N MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525-4275
Practice Address - Country:US
Practice Address - Phone:706-212-0661
Practice Address - Fax:706-212-0662
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R3598225X00000X
GAOT004853225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6801Medicare PIN