Provider Demographics
NPI:1093013906
Name:MAINER, KIMBERLY ANN (MS, OTR/L, CLT-LANA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:MAINER
Suffix:
Gender:F
Credentials:MS, OTR/L, CLT-LANA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:MAINER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, OTR/L, CLT-LANA
Mailing Address - Street 1:2320 HENRY CLOWER BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-7425
Mailing Address - Country:US
Mailing Address - Phone:770-802-4446
Mailing Address - Fax:770-802-4464
Practice Address - Street 1:2321 HENRY CLOWER BLVD STE A
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-7419
Practice Address - Country:US
Practice Address - Phone:770-802-4446
Practice Address - Fax:770-802-4464
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002000225XL0004X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistLow Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I677320Medicare UPIN