Provider Demographics
NPI:1497337372
Name:GIM, PRISCILLA M (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:M
Last Name:GIM
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 ROSECRANS AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-1901
Mailing Address - Country:US
Mailing Address - Phone:714-280-2695
Mailing Address - Fax:
Practice Address - Street 1:1201 ROSECRANS AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-1901
Practice Address - Country:US
Practice Address - Phone:714-280-2695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA22778225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician