Provider Demographics
NPI:1932645124
Name:ELLISTON, KATHERINE (COTA/L)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:ELLISTON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 TOWN AND COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-4031
Mailing Address - Country:US
Mailing Address - Phone:770-548-9071
Mailing Address - Fax:
Practice Address - Street 1:12 TOWN AND COUNTRY DR
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-4031
Practice Address - Country:US
Practice Address - Phone:770-548-9071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR339437224Z00000X
GAOTA001886224Z00000X
TX214384224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant