Provider Demographics
NPI:1205442472
Name:FARRIS, SI'ARA WASHINGTON (ATC, LMT)
Entity type:Individual
Prefix:
First Name:SI'ARA
Middle Name:WASHINGTON
Last Name:FARRIS
Suffix:
Gender:F
Credentials:ATC, LMT
Other - Prefix:
Other - First Name:SI'ARA
Other - Middle Name:SHALAI
Other - Last Name:WASHINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC, LMT
Mailing Address - Street 1:564 HILLANDALE PARK DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-8833
Mailing Address - Country:US
Mailing Address - Phone:843-718-7536
Mailing Address - Fax:
Practice Address - Street 1:564 HILLANDALE PARK DR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-8833
Practice Address - Country:US
Practice Address - Phone:843-718-7536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9454225700000X
GAAT0038702255A2300X
SC14182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist