Healthcare Provider Details

I. General information

NPI: 1083107536
Provider Name (Legal Business Name): KELLEY IRENE HULTEEN COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2018
Last Update Date: 06/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4409 N WASSERMAN WAY
SALINA KS
67401-9247
US

IV. Provider business mailing address

4409 N WASSERMAN WAY
SALINA KS
67401-9247
US

V. Phone/Fax

Practice location:
  • Phone: 785-577-3161
  • Fax:
Mailing address:
  • Phone: 785-577-3161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number18-00920
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: