Provider Demographics
NPI:1104439975
Name:DICKERSON, SHANAVIA NATAE
Entity type:Individual
Prefix:
First Name:SHANAVIA
Middle Name:NATAE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1731 TILDEN AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-3744
Mailing Address - Country:US
Mailing Address - Phone:470-549-5131
Mailing Address - Fax:
Practice Address - Street 1:1731 TILDEN AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3744
Practice Address - Country:US
Practice Address - Phone:470-549-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT012487225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty