1265303804 NPI number — SHANDA DANIELLE HENRY MS, LAT, ATC

Table of content: SHANDA DANIELLE HENRY MS, LAT, ATC (NPI 1265303804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265303804 NPI number — SHANDA DANIELLE HENRY MS, LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENRY
Provider First Name:
SHANDA
Provider Middle Name:
DANIELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LAT, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CALLENBACK
Provider Other First Name:
SHANDA
Provider Other Middle Name:
DANIELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS,LAT, ATC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265303804
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
82 SAND PUMP LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEMONT
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30552-2921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-490-1430
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230 WILDCAT TRAIL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIGER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-490-1430
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/16/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207PS0010X , with the licence number:  AT002799 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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