Provider Demographics
NPI:1295121309
Name:SHACKLEFORD, SARA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:SHACKLEFORD
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 1:470 BLANDENBURG RD
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30116-8971
Mailing Address - Country:US
Mailing Address - Phone:678-634-2887
Mailing Address - Fax:
Practice Address - Street 1:2280 HIGHWAY 29 N
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1031
Practice Address - Country:US
Practice Address - Phone:770-683-6833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001878224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant