Provider Demographics
NPI:1356905038
Name:PHRAKONEKHAM, MICK (OC60942789)
Entity type:Individual
Prefix:
First Name:MICK
Middle Name:
Last Name:PHRAKONEKHAM
Suffix:
Gender:M
Credentials:OC60942789
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25117 SW PARKWAY AVE
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2717 DEXTER AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-1914
Practice Address - Country:US
Practice Address - Phone:206-284-7012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-27
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant