Provider Demographics
NPI:1033485594
Name:PARK, JUSTINE MICHELLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:MICHELLE
Last Name:PARK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:MICHELLE
Other - Last Name:TEKAWA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:43555 GRIMMER BLVD APT B115
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-5981
Mailing Address - Country:US
Mailing Address - Phone:510-274-7600
Mailing Address - Fax:
Practice Address - Street 1:43555 GRIMMER BLVD APT B115
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-5981
Practice Address - Country:US
Practice Address - Phone:510-274-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11173225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist