Provider Demographics
NPI:1285114918
Name:SAMPLES, SHANNON (COTA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SAMPLES
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 1:115 OVERHILL DR
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-1839
Mailing Address - Country:US
Mailing Address - Phone:972-824-3980
Mailing Address - Fax:
Practice Address - Street 1:115 OVERHILL DR
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-1839
Practice Address - Country:US
Practice Address - Phone:972-824-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX211812224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant