Healthcare Provider Details

I. General information

NPI: 1295207892
Provider Name (Legal Business Name): OKULA MATATA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

746 S MAIN ST
LAYTON UT
84041-4229
US

IV. Provider business mailing address

962 N 3550 W
LAYTON UT
84041-3451
US

V. Phone/Fax

Practice location:
  • Phone: 602-697-5808
  • Fax:
Mailing address:
  • Phone: 602-697-5808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: PAWEL OKULA
Title or Position: OWNER
Credential: LMFT
Phone: 602-697-5808