Provider Demographics
NPI:1891451480
Name:SONG, SUE (OTR)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:
Other - Last Name:YANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4640 ADMIRALTY WAY STE 420
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4640 ADMIRALTY WAY STE 420
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6617
Practice Address - Country:US
Practice Address - Phone:424-526-5151
Practice Address - Fax:424-835-6475
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25057225X00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist