Provider Demographics
NPI:1376604637
Name:CAMMISA, KATHRYNE (OT)
Entity Type:Individual
Prefix:
First Name:KATHRYNE
Middle Name:
Last Name:CAMMISA
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 1:1216 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 BARNWELL AVE NE
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-4406
Practice Address - Country:US
Practice Address - Phone:803-641-4144
Practice Address - Fax:804-641-4147
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC216225X00000X
GAOT000368225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA318108OtherWELLCARE
GA10033920OtherAMERIGROUP
GA000634389EMedicaid
SCPH0015Medicaid