Provider Demographics
NPI:1740402577
Name:SOTOLONGO, KOLLIN
Entity Type:Individual
Prefix:MRS
First Name:KOLLIN
Middle Name:
Last Name:SOTOLONGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9285 MILLSTONE RETREAT LN
Mailing Address - Street 2:
Mailing Address - City:TOBINSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47520-5866
Mailing Address - Country:US
Mailing Address - Phone:317-201-0446
Mailing Address - Fax:
Practice Address - Street 1:9285 MILLSTONE RETREAT LN
Practice Address - Street 2:
Practice Address - City:TOBINSPORT
Practice Address - State:IN
Practice Address - Zip Code:47520-5866
Practice Address - Country:US
Practice Address - Phone:317-201-0446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99025195A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200847560Medicaid