Provider Demographics
NPI:1013477223
Name:SHIN, IRENE
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6160 CORNERSTONE CT E STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3724
Mailing Address - Country:US
Mailing Address - Phone:858-216-8837
Mailing Address - Fax:619-941-0276
Practice Address - Street 1:21515 HAWTHORNE BLVD STE G100
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-6501
Practice Address - Country:US
Practice Address - Phone:424-571-2618
Practice Address - Fax:424-571-2339
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24407225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics