Provider Demographics
NPI:1689965154
Name:KIM, TINA (OTR/L)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40680 CALIFORNIA OAKS RD
Mailing Address - Street 2:STE 2A
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5755
Mailing Address - Country:US
Mailing Address - Phone:951-894-4800
Mailing Address - Fax:951-894-4804
Practice Address - Street 1:29995 TECHNOLOGY DR
Practice Address - Street 2:SUITE 103
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-2632
Practice Address - Country:US
Practice Address - Phone:951-304-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13805225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist