Provider Demographics
NPI:1508497983
Name:HANISH, KILEY KREKORIAN (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:KREKORIAN
Last Name:HANISH
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 1:1671 VERANADA AVE
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-3627
Mailing Address - Country:US
Mailing Address - Phone:310-403-3856
Mailing Address - Fax:
Practice Address - Street 1:1671 VERANADA AVE
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-3627
Practice Address - Country:US
Practice Address - Phone:310-403-3856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5640225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist