Provider Demographics
NPI:1710437629
Name:SHELTON, KATESSIA LEANN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:KATESSIA
Middle Name:LEANN
Last Name:SHELTON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E MAIN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-4891
Mailing Address - Country:US
Mailing Address - Phone:423-722-2062
Mailing Address - Fax:243-722-2062
Practice Address - Street 1:401 E MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4891
Practice Address - Country:US
Practice Address - Phone:423-722-2062
Practice Address - Fax:243-722-2062
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2782224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant