Provider Demographics
NPI:1689124596
Name:FORSBERG, ALICIA KERRI (COTA/L)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:KERRI
Last Name:FORSBERG
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:KERRI
Other - Middle Name:
Other - Last Name:FORSBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA/L
Mailing Address - Street 1:1691 DEXTER LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-8660
Mailing Address - Country:US
Mailing Address - Phone:843-343-2003
Mailing Address - Fax:
Practice Address - Street 1:2230 ASHLEY CROSSING DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5700
Practice Address - Country:US
Practice Address - Phone:843-766-5228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCOTA.3357224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant