Provider Demographics
NPI:1588122402
Name:GAYLOR, KRISTINE ELIZABETH (COTA/L)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ELIZABETH
Last Name:GAYLOR
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1439 SUMMIT WAY
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 WASHINGTON COMMONS DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3159
Practice Address - Country:US
Practice Address - Phone:844-530-9722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-10
Last Update Date:2019-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001947224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant