Provider Demographics
NPI:1982038006
Name:SOTELO, JILLIANE ELISE (MS, LCGC)
Entity Type:Individual
Prefix:
First Name:JILLIANE
Middle Name:ELISE
Last Name:SOTELO
Suffix:
Gender:F
Credentials:MS, LCGC
Other - Prefix:
Other - First Name:JILLIANE
Other - Middle Name:ELISE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LCGC
Mailing Address - Street 1:55 LAKE AVE N # A3104
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01655-0002
Mailing Address - Country:US
Mailing Address - Phone:774-443-7646
Mailing Address - Fax:774-442-3525
Practice Address - Street 1:55 LAKE AVE N # A3104
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:774-443-7646
Practice Address - Fax:774-442-3525
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAGC145170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS