MEDICARE: MRS. MICHELLE G SHEPHERD MSOTRL

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	225XP0200X	Pediatric Occupational Therapist	OT003006	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	930129	OTHER	GA	BCBS PIN

General Provider Information

NPI Number	:	1366508921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELLE G SHEPHERD MSOTRL

Provider Business Mailing Address
First Line	:	700 AMSTER GREEN DR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30350-4139
Country	:	US
Telephone Number	:	770-851-9553
Fax Number	:	770-698-4178

Provider Business Practice Location Address
First Line	:	1000 HOLCOMB WOODS PKWY
Second Line	:	STE426
City	:	ROSWELL
State	:	GA
Zip	:	30076-2575
Country	:	US
Telephone Number	:	770-641-8070
Fax Number	:	770-698-4178

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

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	05/20/2008

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