Provider Demographics
NPI:1457924342
Name:SHOCKLEY, STEPHANIE (LMT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SHOCKLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 LAWRENCEVILLE HWY APT D4
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5230
Mailing Address - Country:US
Mailing Address - Phone:404-764-8499
Mailing Address - Fax:
Practice Address - Street 1:3535 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5805
Practice Address - Country:US
Practice Address - Phone:404-764-8499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT008898225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMT008898OtherGEORGIA BOARD OF MASSAGE THERAPY