Provider Demographics
NPI:1689341380
Name:VAN AUDENHOVE, SHELLY (COTA)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:VAN AUDENHOVE
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 1:3904 CLAYTON RD W
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-7926
Mailing Address - Country:US
Mailing Address - Phone:469-212-3455
Mailing Address - Fax:
Practice Address - Street 1:404 RACQUET CLUB BLVD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6408
Practice Address - Country:US
Practice Address - Phone:682-738-3056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216931224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant