Provider Demographics
NPI:1184381857
Name:MILLER, SHANTEL LAREA (COTA/L)
Entity type:Individual
Prefix:
First Name:SHANTEL
Middle Name:LAREA
Last Name:MILLER
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 1:204 LACEY LN UNIT D
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-5535
Mailing Address - Country:US
Mailing Address - Phone:918-974-5650
Mailing Address - Fax:
Practice Address - Street 1:2300 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2009
Practice Address - Country:US
Practice Address - Phone:918-962-0198
Practice Address - Fax:844-632-7298
Is Sole Proprietor?:No
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2141224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant