Provider Demographics
NPI:1619526399
Name:SALAS, KELLY (COTA/L)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SALAS
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 1:902 W BADGER RD APT 8
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-2448
Mailing Address - Country:US
Mailing Address - Phone:715-220-2670
Mailing Address - Fax:
Practice Address - Street 1:701 DEMING WAY STE 110
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-2916
Practice Address - Country:US
Practice Address - Phone:608-819-6394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5650-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant