Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | OT 005074 | GA |
NPI | 1356723647 |
---|---|
Provider Name | Kelsey Thornton |
First Address | Marietta, GA 30066-6157 |
Second Address | Marietta, GA 30066-6157 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2015 |
Last Update Date | 22/07/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
OT 005075 | GA OT LICENSE (01) | GA |