Provider Demographics
NPI:1619296233
Name:ALLEN, JUDITH CARR (OTR)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:CARR
Last Name:ALLEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 CASTLE DR
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-2292
Mailing Address - Country:US
Mailing Address - Phone:706-296-6619
Mailing Address - Fax:
Practice Address - Street 1:1170 CASTLE DR
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-2292
Practice Address - Country:US
Practice Address - Phone:706-296-6619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT000341225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT000341OtherGEORGIA STATE OCCUPATIONAL THERAPY LICENSE