Provider Demographics
NPI:1558088047
Name:JIM, CALVIN
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:
Last Name:JIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10230 MURTY LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-3765
Mailing Address - Country:US
Mailing Address - Phone:267-815-3376
Mailing Address - Fax:
Practice Address - Street 1:9815 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1035
Practice Address - Country:US
Practice Address - Phone:215-677-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC018714225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty