Provider Demographics
NPI:1669519823
Name:GATHERS, KEIRA JEAN (MOT)
Entity type:Individual
Prefix:MISS
First Name:KEIRA
Middle Name:JEAN
Last Name:GATHERS
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:MRS
Other - First Name:KEIRA
Other - Middle Name:JEAN
Other - Last Name:HANBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT
Mailing Address - Street 1:2028 GALTY LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-1147
Mailing Address - Country:US
Mailing Address - Phone:980-322-2185
Mailing Address - Fax:
Practice Address - Street 1:3007 SIMMON TREE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-0676
Practice Address - Country:US
Practice Address - Phone:704-995-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI618225X00000X
NC7155225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7302220Medicaid