Provider Demographics
NPI:1558968321
Name:SONG, KATHERINE GEEEUN
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:GEEEUN
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1781 N BENTON WAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-1478
Mailing Address - Country:US
Mailing Address - Phone:818-524-8581
Mailing Address - Fax:
Practice Address - Street 1:31248 OAK CREST DR STE 120
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-5673
Practice Address - Country:US
Practice Address - Phone:818-926-9057
Practice Address - Fax:818-647-6600
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16207225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist