Provider Demographics
NPI:1134620917
Name:HENLEY, SHONDA SHAREE (COTA)
Entity type:Individual
Prefix:MRS
First Name:SHONDA
Middle Name:SHAREE
Last Name:HENLEY
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 1:11150 KEATCHIE MARSHALL RD
Mailing Address - Street 2:
Mailing Address - City:KEATCHIE
Mailing Address - State:LA
Mailing Address - Zip Code:71046-9301
Mailing Address - Country:US
Mailing Address - Phone:318-401-4713
Mailing Address - Fax:
Practice Address - Street 1:4062 SUMMERHILL SQ
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2730
Practice Address - Country:US
Practice Address - Phone:318-401-4713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212219224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant