Provider Demographics
NPI:1144479619
Name:POETTKER, NEELY R (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:NEELY
Middle Name:R
Last Name:POETTKER
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:NEELY
Other - Middle Name:R
Other - Last Name:KIPLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:14163 JEM DR
Mailing Address - Street 2:
Mailing Address - City:AVISTON
Mailing Address - State:IL
Mailing Address - Zip Code:62216-3646
Mailing Address - Country:US
Mailing Address - Phone:618-401-3210
Mailing Address - Fax:618-228-7229
Practice Address - Street 1:14163 JEM DR
Practice Address - Street 2:
Practice Address - City:AVISTON
Practice Address - State:IL
Practice Address - Zip Code:62216-3646
Practice Address - Country:US
Practice Address - Phone:618-401-3210
Practice Address - Fax:618-228-7229
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-007649225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist