Provider Demographics
NPI:1013499789
Name:NOWELL, CHANNA (COTA)
Entity Type:Individual
Prefix:
First Name:CHANNA
Middle Name:
Last Name:NOWELL
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 1:1702 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-1838
Mailing Address - Country:US
Mailing Address - Phone:325-451-9839
Mailing Address - Fax:
Practice Address - Street 1:5455 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7711
Practice Address - Country:US
Practice Address - Phone:325-944-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213347224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant