Provider Demographics
NPI:1609480979
Name:ETTRESS, LA SHAN BRIDGET (MT)
Entity Type:Individual
Prefix:MS
First Name:LA SHAN
Middle Name:BRIDGET
Last Name:ETTRESS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 POSTMASTER DR UNIT 3082
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-2832
Mailing Address - Country:US
Mailing Address - Phone:678-719-9703
Mailing Address - Fax:
Practice Address - Street 1:1660 NEIGHBORHOOD WALK
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-8645
Practice Address - Country:US
Practice Address - Phone:323-835-7306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT012485225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist