Provider Demographics
NPI:1821609835
Name:HOUSTON, SHONTA MONIQUE (ATC, PTA)
Entity Type:Individual
Prefix:
First Name:SHONTA
Middle Name:MONIQUE
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LINK ST APT 3L
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-4430
Mailing Address - Country:US
Mailing Address - Phone:478-335-7488
Mailing Address - Fax:
Practice Address - Street 1:110 LINK ST APT 3L
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-4430
Practice Address - Country:US
Practice Address - Phone:478-335-7488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004442225200000X
GAAT0025622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant