Provider Demographics
NPI:1932655248
Name:BROOKS, SHALA
Entity Type:Individual
Prefix:
First Name:SHALA
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHALA
Other - Middle Name:DEONE
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSOTR/L
Mailing Address - Street 1:106 VOGEL CT
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-3873
Mailing Address - Country:US
Mailing Address - Phone:706-207-1985
Mailing Address - Fax:
Practice Address - Street 1:106 VOGEL CT
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-3873
Practice Address - Country:US
Practice Address - Phone:706-207-1985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-27
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005557225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist