Provider Demographics
NPI:1770258402
Name:KIM, CHRISTINE (OT)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 SW MARLOW AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5186
Mailing Address - Country:US
Mailing Address - Phone:503-292-0765
Mailing Address - Fax:503-292-5208
Practice Address - Street 1:1815 SW MARLOW AVE STE 110
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5186
Practice Address - Country:US
Practice Address - Phone:503-292-0765
Practice Address - Fax:503-292-5208
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR394862225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist