Provider Demographics
NPI:1356854129
Name:DJOURAEV, ARTEM
Entity Type:Individual
Prefix:
First Name:ARTEM
Middle Name:
Last Name:DJOURAEV
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ARTEM
Other - Middle Name:
Other - Last Name:DJOURAEV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1318 CAROLYN DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3547
Mailing Address - Country:US
Mailing Address - Phone:678-860-3245
Mailing Address - Fax:
Practice Address - Street 1:1456 MCLENDON DR STE B
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-1848
Practice Address - Country:US
Practice Address - Phone:404-728-9766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006857225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics