Provider Demographics
NPI:1164054573
Name:GULLA, KAELIN DEANNA (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:KAELIN
Middle Name:DEANNA
Last Name:GULLA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2259 BLUEGRAMA DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41005-6801
Mailing Address - Country:US
Mailing Address - Phone:317-908-1488
Mailing Address - Fax:
Practice Address - Street 1:2259 BLUEGRAMA DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KY
Practice Address - Zip Code:41005-6801
Practice Address - Country:US
Practice Address - Phone:317-908-1488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY165360224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty