Provider Demographics
NPI:1386176428
Name:KELSO-OTIENO, MICAELA (ATC)
Entity type:Individual
Prefix:
First Name:MICAELA
Middle Name:
Last Name:KELSO-OTIENO
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:MICAELA
Other - Middle Name:
Other - Last Name:KELSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC
Mailing Address - Street 1:580 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:NE
Mailing Address - Zip Code:68333-3101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1014 BOSWELL AVE
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:NE
Practice Address - Zip Code:68333-2426
Practice Address - Country:US
Practice Address - Phone:402-826-8328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer