Provider Demographics
NPI:1336513555
Name:COENEN, SHANDRA (PTA)
Entity type:Individual
Prefix:
First Name:SHANDRA
Middle Name:
Last Name:COENEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 IRVINE BLVD
Mailing Address - Street 2:361
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-8008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2480 IRVINE BLVD
Practice Address - Street 2:361
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92782-8008
Practice Address - Country:US
Practice Address - Phone:714-587-1674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-26
Last Update Date:2015-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10791225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant