Provider Demographics
NPI:1508591397
Name:COULTER, KAITLIN RITA (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:RITA
Last Name:COULTER
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8929 OXFORD ST
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-4966
Mailing Address - Country:US
Mailing Address - Phone:630-487-1190
Mailing Address - Fax:
Practice Address - Street 1:750 PASQUINELLI DR STE 204
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1291
Practice Address - Country:US
Practice Address - Phone:630-560-0136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.014987225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist