Provider Demographics
NPI:1649869264
Name:VIRGIL, SHAJUAN (CPED, LMT)
Entity type:Individual
Prefix:
First Name:SHAJUAN
Middle Name:
Last Name:VIRGIL
Suffix:
Gender:F
Credentials:CPED, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2428
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-0008
Mailing Address - Country:US
Mailing Address - Phone:678-682-4493
Mailing Address - Fax:
Practice Address - Street 1:108 BAYTREE DR
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-8861
Practice Address - Country:US
Practice Address - Phone:678-682-4493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACPED4585224L00000X
GAMT001526225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist