Provider Demographics
NPI:1932645173
Name:SOUTH, KATIE (OT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:SOUTH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 SANDY CROSS RD
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-3371
Mailing Address - Country:US
Mailing Address - Phone:706-491-8428
Mailing Address - Fax:
Practice Address - Street 1:68
Practice Address - Street 2:SPRING STATION ROAD
Practice Address - City:FRANKLIN SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30639-3063
Practice Address - Country:US
Practice Address - Phone:706-491-8428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006629225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003184538AMedicaid