Basic Information
| Provider Information | |||||||||
| NPI: | 1619636123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KULINA | ||||||||
| FirstName: | MACKENZIE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4303 CREST RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303448116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175991791 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1603 GEORGIA HIGHWAY 20 NE STE 201 | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300123946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709298411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2021 | ||||||||
| LastUpdateDate: | 12/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0019X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.