Provider Demographics
NPI:1891700191
Name:MORGAN, KIMBERLY ANN (OTRL HTC PAM LLCC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:MORGAN
Suffix:
Gender:F
Credentials:OTRL HTC PAM LLCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6692 MERCHANDISE WAY
Mailing Address - Street 2:#C
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619-9453
Mailing Address - Country:US
Mailing Address - Phone:530-621-1149
Mailing Address - Fax:530-626-3049
Practice Address - Street 1:6692 MERCHANDISE WAY
Practice Address - Street 2:#C
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-9453
Practice Address - Country:US
Practice Address - Phone:530-621-1149
Practice Address - Fax:530-626-3049
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT776225X00000X, 225XE1200X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomics
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ05534ZOtherBS
CA6623800001Medicare NSC
CAZZZ05534ZOtherBS