Provider Demographics
NPI:1215036033
Name:CHAKRABORTY, KOUSHICK (OTR/L)
Entity Type:Individual
Prefix:
First Name:KOUSHICK
Middle Name:
Last Name:CHAKRABORTY
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 VANLEER AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2306
Mailing Address - Country:US
Mailing Address - Phone:423-434-2200
Mailing Address - Fax:423-434-2200
Practice Address - Street 1:3209 BRISTOL HWY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1515
Practice Address - Country:US
Practice Address - Phone:423-282-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOT0000003621225X00000X
CAOT 5031225X00000X
AROTR1219225X00000X
VA0119004307225X00000X
TX108485225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist