Provider Demographics
NPI:1427741925
Name:SRIKANCHANA, PHU THO
Entity type:Individual
Prefix:
First Name:PHU THO
Middle Name:
Last Name:SRIKANCHANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-3119
Mailing Address - Country:US
Mailing Address - Phone:404-423-2038
Mailing Address - Fax:
Practice Address - Street 1:1894 LUDOVIE LN
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-1044
Practice Address - Country:US
Practice Address - Phone:678-626-0557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT008486225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist