Basic Information
| Provider Information | |||||||||
| NPI: | 1952521171 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5173 WAGON WHEEL AVE | ||||||||
| Address2: | |||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796065340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256915805 | ||||||||
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| Practice Location | |||||||||
| Address1: | HENDRICK HEALTH SYSTEM | ||||||||
| Address2: | 1900 PINE STREET | ||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256928080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 207938 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.