Provider Demographics
NPI:1326415043
Name:BLACK, KIMBERLY (COTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:TUNNEL HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30755-6800
Mailing Address - Country:US
Mailing Address - Phone:423-463-6531
Mailing Address - Fax:
Practice Address - Street 1:2403 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-4033
Practice Address - Country:US
Practice Address - Phone:706-866-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001922224Z00000X
TN2530224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant