Provider Demographics
NPI:1629301098
Name:SMALLIDGE, KATHLEEN (MS, OTR/L)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:SMALLIDGE
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 1:2206 GLENDALE RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-3434
Mailing Address - Country:US
Mailing Address - Phone:646-385-1534
Mailing Address - Fax:
Practice Address - Street 1:2206 GLENDALE RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-3434
Practice Address - Country:US
Practice Address - Phone:646-385-1534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015850225X00000X
GAOT005985225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist