Healthcare Provider Details

I. General information

NPI: 1720655103
Provider Name (Legal Business Name): TATSUICHI OKU LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2021
Last Update Date: 06/05/2021
Certification Date: 06/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2916 GRAND CONCOURSE
BRONX NY
10458-2783
US

IV. Provider business mailing address

2916 GRAND CONCOURSE
BRONX NY
10458-2783
US

V. Phone/Fax

Practice location:
  • Phone: 917-659-9990
  • Fax:
Mailing address:
  • Phone: 917-659-9990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number109560
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: