Provider Demographics
NPI:1679026074
Name:EDWARDS, KENNETH EUGENE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:EUGENE
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 STONEBRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-2077
Mailing Address - Country:US
Mailing Address - Phone:706-614-8535
Mailing Address - Fax:
Practice Address - Street 1:1020 STONEBRIDGE CIR
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-2077
Practice Address - Country:US
Practice Address - Phone:706-614-8535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002775225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist