Provider Demographics
NPI:1356414999
Name:PETERS, KIMBERLY JACKSON (OTRL)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JACKSON
Last Name:PETERS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 HIGHLAND LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-3917
Mailing Address - Country:US
Mailing Address - Phone:770-418-1778
Mailing Address - Fax:
Practice Address - Street 1:3483 SATELLITE BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8692
Practice Address - Country:US
Practice Address - Phone:770-418-1778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT000887225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist