Provider Demographics
NPI:1184866899
Name:RUSSELL, KIM KOEHLER (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:KOEHLER
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 COLIMA STREET
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:619-894-9398
Mailing Address - Fax:
Practice Address - Street 1:3666 KEARNY VILLA RD
Practice Address - Street 2:SUITE 308
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1951
Practice Address - Country:US
Practice Address - Phone:858-505-5460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-26
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9543225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand