Provider Demographics
NPI:1053087148
Name:MILLS, SHELLY (OTA)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:MILLS
Suffix:
Gender:F
Credentials:OTA
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 542
Mailing Address - Street 2:
Mailing Address - City:MOUNT ENTERPRISE
Mailing Address - State:TX
Mailing Address - Zip Code:75681-0542
Mailing Address - Country:US
Mailing Address - Phone:903-658-1418
Mailing Address - Fax:855-232-8604
Practice Address - Street 1:7057 US HIGHWAY 84 E
Practice Address - Street 2:
Practice Address - City:GARRISON
Practice Address - State:TX
Practice Address - Zip Code:75946-3750
Practice Address - Country:US
Practice Address - Phone:903-658-1418
Practice Address - Fax:855-232-8604
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209725224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant