Provider Demographics
NPI:1427125772
Name:WITTGEN, KRISTIN P (OTR)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:P
Last Name:WITTGEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2753 THOMASHIRE TRCE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-4783
Mailing Address - Country:US
Mailing Address - Phone:678-234-9761
Mailing Address - Fax:
Practice Address - Street 1:2753 THOMASHIRE TRCE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-4783
Practice Address - Country:US
Practice Address - Phone:678-234-9761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002916225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000916418AMedicaid