Provider Demographics
NPI:1972285021
Name:SOULIA, KAELIN MARIE
Entity type:Individual
Prefix:
First Name:KAELIN
Middle Name:MARIE
Last Name:SOULIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 WEST ROAD
Mailing Address - Street 2:
Mailing Address - City:MOIRA
Mailing Address - State:NY
Mailing Address - Zip Code:12957-0025
Mailing Address - Country:US
Mailing Address - Phone:315-514-5687
Mailing Address - Fax:
Practice Address - Street 1:64 WEST ROAD
Practice Address - Street 2:
Practice Address - City:MOIRA
Practice Address - State:NY
Practice Address - Zip Code:12957-0025
Practice Address - Country:US
Practice Address - Phone:315-514-5687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY722171869171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator