MEDICARE: MRS. KAREN OSBOURN WAITES MOT, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XG0600X	Gerontology Occupational Therapist	OT005047	GA
2	225XP0200X	Pediatric Occupational Therapist	OT005047	GA

General Provider Information

NPI Number	:	1851539787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KAREN OSBOURN WAITES MOT, OTR/L

Provider Business Mailing Address
First Line	:	136 MARSHS EDGE LN
Second Line	:
City	:	ST SIMONS ISLAND
State	:	GA
Zip	:	31522-8898
Country	:	US
Telephone Number	:	912-634-4774
Fax Number	:

Provider Business Practice Location Address
First Line	:	4212 CORAL PARK DR
Second Line	:
City	:	BRUNSWICK
State	:	GA
Zip	:	31520-3016
Country	:	US
Telephone Number	:	912-342-8875
Fax Number	:	912-342-8016

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2009
Last Update Date	:	11/06/2021

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