Provider Demographics
NPI:1023343092
Name:WHITE, KELLY ALAN (COTA/L)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:ALAN
Last Name:WHITE
Suffix:
Gender:M
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 1:4334 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-2837
Mailing Address - Country:US
Mailing Address - Phone:630-971-0815
Mailing Address - Fax:
Practice Address - Street 1:4334 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2837
Practice Address - Country:US
Practice Address - Phone:630-971-0815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-08
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.000794224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant