MEDICARE: SHELBY WOODALL

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	225700000X	Massage Therapist	MT-23019	AZ
2	225700000X	Massage Therapist	MT011771	GA

General Provider Information

NPI Number	:	1912438110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELBY WOODALL

Provider Business Mailing Address
First Line	:	728 WOODMONT DR
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30062-3833
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1154 CONCORD RD SE
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080-4263
Country	:	US
Telephone Number	:	770-855-0679
Fax Number	:

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

Provider Enumeration Date	:	03/21/2017
Last Update Date	:	11/23/2019

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Directions to “ SHELBY WOODALL ” Practice Location

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