Provider Demographics
NPI:1356723647
Name:THORNTON, KELSEY (OT/L)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:THORNTON
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 WILLIAMS DR
Mailing Address - Street 2:113
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6157
Mailing Address - Country:US
Mailing Address - Phone:404-561-4552
Mailing Address - Fax:
Practice Address - Street 1:425 WILLIAMS DR
Practice Address - Street 2:113
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-6157
Practice Address - Country:US
Practice Address - Phone:404-561-4552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT 005074225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT 005075OtherGA OT LICENSE