Provider Demographics
NPI:1922402965
Name:GARDENER, KIMBERLY (OTD, OTR/L, SWC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GARDENER
Suffix:
Gender:F
Credentials:OTD, OTR/L, SWC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:KORETOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTD, OTR/L
Mailing Address - Street 1:1932 14TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-4605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1932 14TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-4605
Practice Address - Country:US
Practice Address - Phone:949-683-0884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-20
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12467225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12467OtherCALIFORNIA BOARD OF OCCUPATIONAL THERAPY