Provider Demographics
NPI:1720609100
Name:BRAY, KIMBERLY (OT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BRAY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:534 OWL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-6285
Mailing Address - Country:US
Mailing Address - Phone:770-361-4124
Mailing Address - Fax:678-290-5587
Practice Address - Street 1:534 OWL CREEK DR
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-6285
Practice Address - Country:US
Practice Address - Phone:770-361-4124
Practice Address - Fax:678-290-5587
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007638225X00000X
GA0071882081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation MedicineGroup - Single Specialty