=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740173343
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAWNTA HALSTEAD-PASSLEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2025
-----------------------------------------------------
Last Update Date | 06/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 HYDE PARK
-----------------------------------------------------
City | WINDER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30680-4543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-458-9662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 HYDE PARK
-----------------------------------------------------
City | WINDER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30680-4543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-458-9662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 014878
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------