Provider Demographics
NPI:1336491836
Name:KIM, ANNIE GRACE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:GRACE
Last Name:KIM
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12121 SHADOW RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-3826
Mailing Address - Country:US
Mailing Address - Phone:818-606-6902
Mailing Address - Fax:
Practice Address - Street 1:12121 SHADOW RIDGE WAY
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91326-3826
Practice Address - Country:US
Practice Address - Phone:818-606-6902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12932225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist