Provider Demographics
NPI:1134006182
Name:SHUPE, LILLY MARIE (ATC, LAT, OTC, OT-SC)
Entity type:Individual
Prefix:
First Name:LILLY
Middle Name:MARIE
Last Name:SHUPE
Suffix:
Gender:F
Credentials:ATC, LAT, OTC, OT-SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:487 WINN WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1700
Mailing Address - Country:US
Mailing Address - Phone:404-251-2090
Mailing Address - Fax:404-251-4471
Practice Address - Street 1:487 WINN WAY STE 100
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1700
Practice Address - Country:US
Practice Address - Phone:404-251-2090
Practice Address - Fax:404-251-4471
Is Sole Proprietor?:No
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA24-0912207XX0005X
GAAT0041242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine