MEDICARE: MS. SHARLENE MAE CHAN DY PT

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	PT008544	GA
2	225100000X	Physical Therapist	PT24159	FL

General Provider Information

NPI Number	:	1629223482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHARLENE MAE CHAN DY PT

Provider Business Mailing Address
First Line	:	1015 PONDEROSA LN
Second Line	:	APARTMENT 4
City	:	DALTON
State	:	GA
Zip	:	30720-3523
Country	:	US
Telephone Number	:	706-659-4263
Fax Number	:

Provider Business Practice Location Address
First Line	:	1013 RIVERBURCH PKWY
Second Line	:	SUITE 4
City	:	DALTON
State	:	GA
Zip	:	30721-8887
Country	:	US
Telephone Number	:	866-261-8090
Fax Number	:	706-226-7869

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

Provider Enumeration Date	:	11/20/2008
Last Update Date	:	11/20/2008

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