MEDICARE: SHONTEL M LOPEZ COTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	215990	TX

General Provider Information

NPI Number	:	1033756226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHONTEL M LOPEZ COTA

Provider Business Mailing Address
First Line	:	PO BOX 803703
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75380-3703
Country	:	US
Telephone Number	:	575-571-1673
Fax Number	:

Provider Business Practice Location Address
First Line	:	5800 PRESTON OAKS RD APT 1027
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75254-8707
Country	:	US
Telephone Number	:	575-571-1673
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2019
Last Update Date	:	12/06/2019

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