Healthcare Provider Details

I. General information

NPI: 1770448441
Provider Name (Legal Business Name): NIYA COOKS OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 E LAKE BLVD STE 101
VANCLEAVE MS
39565-6771
US

IV. Provider business mailing address

6300 E LAKE BLVD STE 301
VANCLEAVE MS
39565-6771
US

V. Phone/Fax

Practice location:
  • Phone: 228-215-2240
  • Fax: 228-215-2241
Mailing address:
  • Phone: 228-230-2663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-4285
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: