MEDICARE: SHELLEY SMITH DICECCO MSPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT006744	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	592137	OTHER	GA	BCBS GA

General Provider Information

NPI Number	:	1801834163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLEY SMITH DICECCO MSPT

Provider Business Mailing Address
First Line	:	2669 OSBORNE RD NE
Second Line	:
City	:	BROOKHAVEN
State	:	GA
Zip	:	30319-8400
Country	:	US
Telephone Number	:	404-477-7777
Fax Number	:	404-477-7000

Provider Business Practice Location Address
First Line	:	2669 OSBORNE RD NE
Second Line	:
City	:	BROOKHAVEN
State	:	GA
Zip	:	30319-8400
Country	:	US
Telephone Number	:	404-477-7777
Fax Number	:	404-477-7000

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	04/22/2015

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