Provider Demographics
NPI:1841221199
Name:SMITH, SHANNON MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 17TH ST
Mailing Address - Street 2:SUITE 407
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-3500
Mailing Address - Country:US
Mailing Address - Phone:706-321-0930
Mailing Address - Fax:706-571-0960
Practice Address - Street 1:705 17TH ST
Practice Address - Street 2:SUITE 407
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3500
Practice Address - Country:US
Practice Address - Phone:706-321-0930
Practice Address - Fax:706-571-0960
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA004876OtherGA PT LICENSE NUMBER