Provider Demographics
NPI:1306724745
Name:SHEPHARD, CHARIS D (COTA/L)
Entity type:Individual
Prefix:
First Name:CHARIS
Middle Name:D
Last Name:SHEPHARD
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9975 NEUCHATEL CRES
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-6596
Mailing Address - Country:US
Mailing Address - Phone:770-899-4092
Mailing Address - Fax:
Practice Address - Street 1:2327 N HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-6701
Practice Address - Country:US
Practice Address - Phone:770-834-4404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA002282224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant