Provider Demographics
NPI:1447796651
Name:SHEPHERD, KATELYN JEAN (COTA)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:JEAN
Last Name:SHEPHERD
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 1:402 SE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORELAND
Mailing Address - State:OK
Mailing Address - Zip Code:73852-9064
Mailing Address - Country:US
Mailing Address - Phone:580-994-5570
Mailing Address - Fax:
Practice Address - Street 1:402 SE 6TH ST
Practice Address - Street 2:
Practice Address - City:MOORELAND
Practice Address - State:OK
Practice Address - Zip Code:73852-9064
Practice Address - Country:US
Practice Address - Phone:580-994-5570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1807224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant