Provider Demographics
NPI:1992219067
Name:TITEL, KELLY (COTA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:TITEL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:SCHOENFELDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:11054 SPOOK CAVE RD
Mailing Address - Street 2:
Mailing Address - City:MC GREGOR
Mailing Address - State:IA
Mailing Address - Zip Code:52157-8664
Mailing Address - Country:US
Mailing Address - Phone:563-880-8177
Mailing Address - Fax:
Practice Address - Street 1:700 S FREMONT ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-2331
Practice Address - Country:US
Practice Address - Phone:608-326-8471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087443224Z00000X
WI5395224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant