Provider Demographics
NPI:1740841832
Name:SONG, INKOO (COTA)
Entity type:Individual
Prefix:
First Name:INKOO
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 LAKE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-5155
Mailing Address - Country:US
Mailing Address - Phone:940-636-1725
Mailing Address - Fax:
Practice Address - Street 1:11409 N CENTRAL EXPY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-6678
Practice Address - Country:US
Practice Address - Phone:214-239-5728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210350224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant