Healthcare Provider Details

I. General information

NPI: 1013374446
Provider Name (Legal Business Name): BETH SHANNON L.M.T
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 PONCE DE LEON AVE NE STE 1
ATLANTA GA
30308-1910
US

IV. Provider business mailing address

214 PONCE DE LEON AVE NE STE 1
ATLANTA GA
30308-1910
US

V. Phone/Fax

Practice location:
  • Phone: 404-806-0029
  • Fax:
Mailing address:
  • Phone: 404-806-0029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT009847
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License NumberMT009847
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: