Provider Demographics
NPI:1952521171
Name:GREEN, SHELLY RENEE (COTA)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:RENEE
Last Name:GREEN
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 1:5173 WAGON WHEEL AVE
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-5340
Mailing Address - Country:US
Mailing Address - Phone:325-691-5805
Mailing Address - Fax:
Practice Address - Street 1:HENDRICK HEALTH SYSTEM
Practice Address - Street 2:1900 PINE STREET
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601
Practice Address - Country:US
Practice Address - Phone:325-692-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207938224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant