Provider Demographics
NPI:1780889600
Name:NEAL, KELLI M (COTA)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:M
Last Name:NEAL
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 1:3401 MAPLE GROVE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-5013
Mailing Address - Country:US
Mailing Address - Phone:608-845-1000
Mailing Address - Fax:608-845-1001
Practice Address - Street 1:3401 MAPLE GROVE DR
Practice Address - Street 2:ST MARYS CARE CENTER
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-5013
Practice Address - Country:US
Practice Address - Phone:608-845-1000
Practice Address - Fax:608-845-1001
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1209027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40827500Medicaid