Provider Demographics
NPI:1831741032
Name:MONDLOCH, SHELBY NICOLE (OTA/L)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:NICOLE
Last Name:MONDLOCH
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:NICOLE
Other - Last Name:FRANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTA/L
Mailing Address - Street 1:14206 S WINSTON AVE
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-3773
Mailing Address - Country:US
Mailing Address - Phone:918-688-4205
Mailing Address - Fax:
Practice Address - Street 1:4300 S JUNIPER PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-2832
Practice Address - Country:US
Practice Address - Phone:918-259-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1211224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant