Basic Information
| Provider Information | |||||||||
| NPI: | 1710416185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLACK | ||||||||
| FirstName: | SHAWNA | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6397 LEE HWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374212564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4233628684 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 EXCHANGE ST STE B4 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND HILL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313247646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124590072 | ||||||||
| FaxNumber: | 9124590511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2017 | ||||||||
| LastUpdateDate: | 06/08/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT012897 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.