Provider Demographics
NPI:1710381231
Name:EBERSOLD, KRISTIN (OTR/L)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:EBERSOLD
Suffix:
Gender:F
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 1:208 MAXWELL ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-4209
Mailing Address - Country:US
Mailing Address - Phone:404-931-1615
Mailing Address - Fax:
Practice Address - Street 1:208 MAXWELL ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-4209
Practice Address - Country:US
Practice Address - Phone:404-931-1615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2532225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics