Provider Demographics
NPI:1275212623
Name:KIM, TY (OTR/L)
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:TAHYO
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1551 4TH AVE UNIT 507
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-3151
Mailing Address - Country:US
Mailing Address - Phone:831-277-2109
Mailing Address - Fax:
Practice Address - Street 1:84 E J ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-6115
Practice Address - Country:US
Practice Address - Phone:619-425-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT22821225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist