Provider Demographics
NPI:1558774166
Name:PHELPS, SHAWNA RENE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:SHAWNA
Middle Name:RENE
Last Name:PHELPS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 NE LOOP 820
Mailing Address - Street 2:BUSINESS TOWER 1, SUITE 200
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-7209
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:3120 SOUTHWEST FWY STE 612
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77098-4521
Practice Address - Country:US
Practice Address - Phone:713-979-3800
Practice Address - Fax:713-979-3803
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2051091225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant