Provider Demographics
NPI:1043837131
Name:STEPHENS, KARRA KEITH (OTR/L)
Entity Type:Individual
Prefix:
First Name:KARRA
Middle Name:KEITH
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4617 BROKEN ARROW PATH
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-7514
Mailing Address - Country:US
Mailing Address - Phone:770-539-3081
Mailing Address - Fax:
Practice Address - Street 1:273 QUILLIAN ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528-1464
Practice Address - Country:US
Practice Address - Phone:706-865-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004430225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist