Healthcare Provider Details

I. General information

NPI: 1104176759
Provider Name (Legal Business Name): SIMONE AMANDA OKORO OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 OLD WASHINGTON RD
WALDORF MD
20602-3221
US

IV. Provider business mailing address

4140 OLD WASHINGTON RD
WALDORF MD
20602-3221
US

V. Phone/Fax

Practice location:
  • Phone: 301-645-2813
  • Fax: 301-645-9317
Mailing address:
  • Phone: 301-645-2813
  • Fax: 301-645-9317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number06950
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: