Provider Demographics
NPI:1609336288
Name:CARNELL, VICTORIA (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:CARNELL
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 SALEM RD
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-8500
Mailing Address - Country:US
Mailing Address - Phone:706-699-0598
Mailing Address - Fax:
Practice Address - Street 1:536 GRAND SLAM DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-8044
Practice Address - Country:US
Practice Address - Phone:706-854-8434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007315225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist