Provider Demographics
NPI:1275050346
Name:CHRISTIANSEN, SHIRLEY (COTA/L)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:CHRISTIANSEN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3479 SCARLET ROSE
Mailing Address - Street 2:
Mailing Address - City:SCHERTZ
Mailing Address - State:TX
Mailing Address - Zip Code:78154
Mailing Address - Country:US
Mailing Address - Phone:210-452-0372
Mailing Address - Fax:
Practice Address - Street 1:562 S HIGHWAY 123 BYPASS#224
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-7815
Practice Address - Country:US
Practice Address - Phone:210-215-1840
Practice Address - Fax:210-215-1840
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210020224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX224Z00000Medicaid