Provider Demographics
NPI:1073860631
Name:KINGSLAND, KIM-PHUONG (MOT)
Entity Type:Individual
Prefix:MRS
First Name:KIM-PHUONG
Middle Name:
Last Name:KINGSLAND
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 S. PLACENTIA AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-6832
Mailing Address - Country:US
Mailing Address - Phone:714-646-8318
Mailing Address - Fax:714-646-8320
Practice Address - Street 1:740 S. PLACENTIA AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-6832
Practice Address - Country:US
Practice Address - Phone:714-646-8318
Practice Address - Fax:714-646-8320
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
CA16175225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No253Z00000XAgenciesIn Home Supportive Care