Provider Demographics
NPI:1164901450
Name:SALAS, LYNNETTE (COTA)
Entity Type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:
Last Name:SALAS
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 1:515 W LINGLEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-2211
Mailing Address - Country:US
Mailing Address - Phone:254-965-3611
Mailing Address - Fax:254-965-3618
Practice Address - Street 1:925 SANTA FE DR STE 110
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5867
Practice Address - Country:US
Practice Address - Phone:817-599-7714
Practice Address - Fax:254-965-3618
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212594224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172242301Medicaid