Provider Demographics
NPI:1699970665
Name:ELLIOTT, KRISTEN HARBESON (OTRL)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:HARBESON
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MISS
Other - First Name:KRISTEN
Other - Middle Name:LEIGH
Other - Last Name:HARBESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:474 BAKER WOODS TRL
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2783
Mailing Address - Country:US
Mailing Address - Phone:803-221-6535
Mailing Address - Fax:
Practice Address - Street 1:474 BAKER WOODS TRL
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-2783
Practice Address - Country:US
Practice Address - Phone:803-221-6535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2406225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1501Medicaid