MEDICARE: MR. KELLY ALAN WHITE COTA/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	057.000794	IL

General Provider Information

NPI Number	:	1023343092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KELLY ALAN WHITE COTA/L

Provider Business Mailing Address
First Line	:	4334 WASHINGTON ST
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-2837
Country	:	US
Telephone Number	:	630-971-0815
Fax Number	:

Provider Business Practice Location Address
First Line	:	4334 WASHINGTON ST
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-2837
Country	:	US
Telephone Number	:	630-971-0815
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2009
Last Update Date	:	10/08/2009

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