Provider Demographics
NPI:1023440682
Name:KIM, KALLIE (OTR/L)
Entity type:Individual
Prefix:
First Name:KALLIE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1553 W DAYDREAM DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-7212
Mailing Address - Country:US
Mailing Address - Phone:785-213-1894
Mailing Address - Fax:
Practice Address - Street 1:3100 E BUTLER AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-0008
Practice Address - Country:US
Practice Address - Phone:785-213-1894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-008708225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist