Healthcare Provider Details

I. General information

NPI: 1235627092
Provider Name (Legal Business Name): SHELBY L KEFFELER COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 OURAY RD NW
ALBUQUERQUE NM
87120-1381
US

IV. Provider business mailing address

9609 SALEM RD NE
ALBUQUERQUE NM
87112-1351
US

V. Phone/Fax

Practice location:
  • Phone: 505-603-9079
  • Fax:
Mailing address:
  • Phone: 505-603-9079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3429
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: