Healthcare Provider Details

I. General information

NPI: 1891617031
Provider Name (Legal Business Name): SHANNON DIXON BAINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ASHBROOK PL
ATHENS GA
30605-3961
US

IV. Provider business mailing address

111 ASHBROOK PL 111 ASHBROOK PL
ATHENS GA
30605-3961
US

V. Phone/Fax

Practice location:
  • Phone: 706-248-2928
  • Fax:
Mailing address:
  • Phone: 706-248-2928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT006517
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: