Provider Demographics
NPI:1689132805
Name:HENDRICKS, SHANNON (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 CUMBERLAND PKWY SE APT 915
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-4599
Mailing Address - Country:US
Mailing Address - Phone:443-220-8881
Mailing Address - Fax:
Practice Address - Street 1:125 DECATUR ST SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3201
Practice Address - Country:US
Practice Address - Phone:404-413-4069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0030472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer