Provider Demographics
NPI:1033756226
Name:LOPEZ, SHONTEL M (COTA)
Entity Type:Individual
Prefix:
First Name:SHONTEL
Middle Name:M
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 803703
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75380-3703
Mailing Address - Country:US
Mailing Address - Phone:575-571-1673
Mailing Address - Fax:
Practice Address - Street 1:5800 PRESTON OAKS RD APT 1027
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-8707
Practice Address - Country:US
Practice Address - Phone:575-571-1673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215990224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant