Provider Demographics
NPI:1225378565
Name:PIKE-NELSON, KELLY L (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:L
Last Name:PIKE-NELSON
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 1:9024 S SUBURBAN DR
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-9510
Mailing Address - Country:US
Mailing Address - Phone:608-362-3095
Mailing Address - Fax:
Practice Address - Street 1:9024 S SUBURBAN DR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-9510
Practice Address - Country:US
Practice Address - Phone:608-362-3095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-24
Last Update Date:2013-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1333-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant