Provider Demographics
NPI:1760969935
Name:SHACKELFORD, TAYLOR C'MON (EP-C)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:C'MON
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:EP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 GRASSLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-8600
Mailing Address - Country:US
Mailing Address - Phone:678-580-1404
Mailing Address - Fax:
Practice Address - Street 1:1755 GRASSLAND PKWY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004
Practice Address - Country:US
Practice Address - Phone:678-580-1404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist