Provider Demographics
NPI:1972092443
Name:HEROLD, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HEROLD
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 1:3912 ESSEX HEIGHTS TRL
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-6979
Mailing Address - Country:US
Mailing Address - Phone:706-992-9366
Mailing Address - Fax:
Practice Address - Street 1:2045 CENTRE STONE CT STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-4561
Practice Address - Country:US
Practice Address - Phone:706-507-3794
Practice Address - Fax:706-507-3681
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014992225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist