Provider Demographics
NPI:1871998419
Name:BAUER, SHELLY (OTA)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:BAUER
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 S. LOOP 289 SUITE 210
Mailing Address - Street 2:SENTRY PLAZA TWO
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424
Mailing Address - Country:US
Mailing Address - Phone:806-780-4180
Mailing Address - Fax:806-744-7458
Practice Address - Street 1:5225 S. LOOP 286
Practice Address - Street 2:SUITE 210
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-1319
Practice Address - Country:US
Practice Address - Phone:806-780-4180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209127224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant