Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | OT 004152 | GA |
NPI | 1023171451 |
---|---|
Provider Name | Keri S Converse |
First Address | Suwanee, GA 30024-2379 |
Second Address | Buford, GA 30518-3220 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/12/2006 |
Last Update Date | 23/09/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
786554580A | (05) | GA |