Provider Demographics
NPI:1013549237
Name:KIM, YEAJI
Entity Type:Individual
Prefix:
First Name:YEAJI
Middle Name:
Last Name:KIM
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 1:140 TOWN AND COUNTRY DR STE A
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-3965
Mailing Address - Country:US
Mailing Address - Phone:925-743-8905
Mailing Address - Fax:
Practice Address - Street 1:140 TOWN AND COUNTRY DR STE A
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-3965
Practice Address - Country:US
Practice Address - Phone:925-743-8905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2023-09-16
Deactivation Date:2023-07-26
Deactivation Code:
Reactivation Date:2023-08-23
Provider Licenses
StateLicense IDTaxonomies
CA25290225XH1200X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician