Provider Demographics
NPI:1871858977
Name:KJELLBERG, ANGELA ROSE (COTA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:ROSE
Last Name:KJELLBERG
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3775 20TH ST
Mailing Address - Street 2:
Mailing Address - City:ELK MOUND
Mailing Address - State:WI
Mailing Address - Zip Code:54739-4200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 DAVIS ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:WI
Practice Address - Zip Code:54015-9615
Practice Address - Country:US
Practice Address - Phone:715-796-2218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1269-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant