Provider Demographics
NPI:1336857937
Name:PARK, SAM OK (OTR/L)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:OK
Last Name:PARK
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 1:1000 NORTHSIDE DR NW STE 1500
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-5479
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 NORTHSIDE DR NW STE 1500
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-5479
Practice Address - Country:US
Practice Address - Phone:470-347-9119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-11
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT008686225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist