Individual
MRS. TRACI KANALLAKAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
COTA
Contact information
Practice address
13480 WATERWORKS RD, FIELDON, IL 62031-1437
(618) 535-3241
Mailing address
13480 WATERWORKS RD, FIELDON, IL 62031-1437
(618) 535-3241
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
379497
NBCOT CERTIFICATION
—
Enumeration date
03/01/2017
Last updated
03/01/2017
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