Healthcare Provider Details

I. General information

NPI: 1447657580
Provider Name (Legal Business Name): OKSANA KOCHUKOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 BEDFORD AVE
BROOKLYN NY
11235-2527
US

IV. Provider business mailing address

4560 BEDFORD AVE
BROOKLYN NY
11235-2527
US

V. Phone/Fax

Practice location:
  • Phone: 718-404-7090
  • Fax:
Mailing address:
  • Phone: 718-404-7090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number019222
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: