Basic Information
| Provider Information | |||||||||
| NPI: | 1134670771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | KELCIE | ||||||||
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| Credential: | OT | ||||||||
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| OtherLastName: | JACOBS | ||||||||
| OtherFirstName: | KELCIE | ||||||||
| OtherMiddleName: | LAUREN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 460 MALL BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314064801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126445300 | ||||||||
| FaxNumber: | 9126443369 | ||||||||
| Practice Location | |||||||||
| Address1: | 16915 HIGHWAY 67 | ||||||||
| Address2: | SUITE A | ||||||||
| City: | STATESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304585819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126812500 | ||||||||
| FaxNumber: | 9126812025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2016 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT006559 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.