Provider Demographics
NPI:1811599392
Name:BAILEY, SHONDRA
Entity Type:Individual
Prefix:
First Name:SHONDRA
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4351 MAIN ST STE 105
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28075-7428
Mailing Address - Country:US
Mailing Address - Phone:980-319-9506
Mailing Address - Fax:
Practice Address - Street 1:4351 MAIN ST STE 105
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075-7428
Practice Address - Country:US
Practice Address - Phone:980-319-9506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
173C00000X
NC14161225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC16141OtherNC LICENSED MASSAGE AND BODYWORK THERAPIST