Provider Demographics
NPI:1801834163
Name:DICECCO, SHELLEY SMITH (MSPT)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:SMITH
Last Name:DICECCO
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2669 OSBORNE RD NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-8400
Mailing Address - Country:US
Mailing Address - Phone:404-477-7777
Mailing Address - Fax:404-477-7000
Practice Address - Street 1:2669 OSBORNE RD NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-8400
Practice Address - Country:US
Practice Address - Phone:404-477-7777
Practice Address - Fax:404-477-7000
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006744225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA369496714AMedicaid
GA592137OtherBCBS GA
GA369496714AMedicaid