Provider Demographics
NPI:1669679452
Name:SHUPAK, ANGELA JOAN (COTA)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:JOAN
Last Name:SHUPAK
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 1:7508 COUNTY ROAD 296 E
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-1568
Mailing Address - Country:US
Mailing Address - Phone:903-643-9748
Mailing Address - Fax:903-984-6264
Practice Address - Street 1:1901 WHIPPORWILL LN
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3880
Practice Address - Country:US
Practice Address - Phone:903-984-6264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209497225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist