Provider Demographics
NPI:1619458239
Name:NETHERLY, ANQUANETTE EVETTE (COTA)
Entity Type:Individual
Prefix:
First Name:ANQUANETTE
Middle Name:EVETTE
Last Name:NETHERLY
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:PO BOX 1467
Mailing Address - Street 2:
Mailing Address - City:CENTER
Mailing Address - State:TX
Mailing Address - Zip Code:75935-1467
Mailing Address - Country:US
Mailing Address - Phone:936-564-1138
Mailing Address - Fax:
Practice Address - Street 1:611 NW STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75964-3847
Practice Address - Country:US
Practice Address - Phone:936-564-1138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210097224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant