Provider Demographics
NPI:1962061457
Name:SHAKLEE, STUART PAUL (COTA/L)
Entity type:Individual
Prefix:
First Name:STUART
Middle Name:PAUL
Last Name:SHAKLEE
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 HALLS VALLEY RD NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-6719
Mailing Address - Country:US
Mailing Address - Phone:706-676-6802
Mailing Address - Fax:
Practice Address - Street 1:1356 REDMOND ROAD
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165
Practice Address - Country:US
Practice Address - Phone:706-234-8281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001111224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant