Provider Demographics
NPI:1427359389
Name:SORIA, KELLY L (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:L
Last Name:SORIA
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 1:11531 SWINFORD LN
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-9274
Mailing Address - Country:US
Mailing Address - Phone:219-796-9335
Mailing Address - Fax:
Practice Address - Street 1:4560 SE INTERNATION WAY STE 100
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:971-206-2314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003191224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant