Provider Demographics
NPI:1912438110
Name:WOODALL, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:WOODALL
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 1:728 WOODMONT DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-3833
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1154 CONCORD RD SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-4263
Practice Address - Country:US
Practice Address - Phone:770-855-0679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-23019225700000X
GAMT011771225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist