Basic Information
| Provider Information | |||||||||
| NPI: | 1770771115 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARTER | ||||||||
| FirstName: | KENISHA | ||||||||
| MiddleName: | ERONA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MS, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3470 ARBROATH DR | ||||||||
| Address2: | |||||||||
| City: | DOUGLASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301356731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709476862 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312173838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787657000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2007 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT003768 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.