Provider Demographics
NPI:1235324088
Name:SPRINGER, KEISHA MONIQUE (OT)
Entity Type:Individual
Prefix:MISS
First Name:KEISHA
Middle Name:MONIQUE
Last Name:SPRINGER
Suffix:
Gender:F
Credentials:OT
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 360710
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30036-0710
Mailing Address - Country:US
Mailing Address - Phone:678-613-0001
Mailing Address - Fax:
Practice Address - Street 1:5787 MITCHELL CHASE TRL
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-3473
Practice Address - Country:US
Practice Address - Phone:678-613-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002668225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN002668OtherLICENSE