Provider Demographics
NPI:1750584751
Name:MITCHELL, SHANELL (LMT)
Entity type:Individual
Prefix:
First Name:SHANELL
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 NATHAN DEAN BLVD
Mailing Address - Street 2:SUITE 105-313
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-4911
Mailing Address - Country:US
Mailing Address - Phone:678-567-5220
Mailing Address - Fax:
Practice Address - Street 1:5157 JIMMY LEE SMITH PKWY
Practice Address - Street 2:SUITE 209
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2785
Practice Address - Country:US
Practice Address - Phone:678-567-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT000393225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist