Healthcare Provider Details

I. General information

NPI: 1497467591
Provider Name (Legal Business Name): OKOT LYMPHEDEMA THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2022
Last Update Date: 12/20/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 PEACHTREE INDUSTRIAL BLVD STE 103
BERKELEY LAKE GA
30071-5736
US

IV. Provider business mailing address

4720 PEACHTREE INDUSTRIAL BLVD STE 103
BERKELEY LAKE GA
30071-5736
US

V. Phone/Fax

Practice location:
  • Phone: 470-317-7488
  • Fax: 317-436-1199
Mailing address:
  • Phone: 470-317-7488
  • Fax: 317-436-1199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: OKSANA KULIYEV
Title or Position: OWNER/PRACTITIONER
Credential: MS, OT/R, CLT
Phone: 470-317-7488