Provider Demographics
NPI:1336300441
Name:LILES, KATHERINE ROSE (OT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ROSE
Last Name:LILES
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ROSE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:206 BRIDGEWATER TRL
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-4566
Mailing Address - Country:US
Mailing Address - Phone:229-894-1353
Mailing Address - Fax:
Practice Address - Street 1:1004 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3749
Practice Address - Country:US
Practice Address - Phone:229-894-1353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004751225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist