Provider Demographics
NPI:1639552243
Name:WETZEL, KELLI S (COTA/L)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:S
Last Name:WETZEL
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 1:21 PINE ST
Mailing Address - Street 2:
Mailing Address - City:EAST MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11940-1121
Mailing Address - Country:US
Mailing Address - Phone:631-874-4048
Mailing Address - Fax:
Practice Address - Street 1:21 PINE ST
Practice Address - Street 2:
Practice Address - City:EAST MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11940-1121
Practice Address - Country:US
Practice Address - Phone:631-874-4048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008624-1171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor