Provider Demographics
NPI:1679748891
Name:PHILLIPS, SHALA HENDRY (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:SHALA
Middle Name:HENDRY
Last Name:PHILLIPS
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 1:64 VICTORIA LN
Mailing Address - Street 2:
Mailing Address - City:LAVONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30553-1450
Mailing Address - Country:US
Mailing Address - Phone:706-498-4215
Mailing Address - Fax:706-335-5383
Practice Address - Street 1:64 VICTORIA LN
Practice Address - Street 2:
Practice Address - City:LAVONIA
Practice Address - State:GA
Practice Address - Zip Code:30553-1450
Practice Address - Country:US
Practice Address - Phone:706-498-4215
Practice Address - Fax:706-335-5383
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003215225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist