Provider Demographics
NPI:1194988352
Name:LEATHERWOOD, KATHRYN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:LEATHERWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 OLD NORCROSS ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046
Mailing Address - Country:US
Mailing Address - Phone:678-377-2833
Mailing Address - Fax:678-377-2882
Practice Address - Street 1:545 OLD NORCROSS ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:678-377-2833
Practice Address - Fax:678-377-2882
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004767225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist