Provider Demographics
NPI:1164642930
Name:CRAIG, KIMBERLY LOGAN (COTAL)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LOGAN
Last Name:CRAIG
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-0097
Mailing Address - Country:US
Mailing Address - Phone:864-246-7396
Mailing Address - Fax:
Practice Address - Street 1:3400 ANDERSON RD
Practice Address - Street 2:STE C
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611
Practice Address - Country:US
Practice Address - Phone:864-295-9890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2499224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant