Provider Demographics
NPI:1598346686
Name:MASSENBURG, SHEQUITTA WILKES (LRT, CTRS)
Entity Type:Individual
Prefix:
First Name:SHEQUITTA
Middle Name:WILKES
Last Name:MASSENBURG
Suffix:
Gender:F
Credentials:LRT, CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 LOOP RD EAST
Mailing Address - Street 2:REHAB MEDICINE-RECREATION THERAPY
Mailing Address - City:TUSCALOSSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404
Mailing Address - Country:US
Mailing Address - Phone:205-554-2000
Mailing Address - Fax:
Practice Address - Street 1:3701 LOOP RD EAST
Practice Address - Street 2:REHAB MEDICINE-RECREATION THERAPY
Practice Address - City:TUSCALOSSA
Practice Address - State:AL
Practice Address - Zip Code:35404
Practice Address - Country:US
Practice Address - Phone:205-554-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC55100225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist