Provider Demographics
NPI:1295251361
Name:MCCONNELL, AMANDA KIM (OTR/L)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KIM
Last Name:MCCONNELL
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 1:848 STARCREST ST
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-2050
Mailing Address - Country:US
Mailing Address - Phone:714-392-2177
Mailing Address - Fax:
Practice Address - Street 1:21615 HAWTHORNE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-6670
Practice Address - Country:US
Practice Address - Phone:310-371-8555
Practice Address - Fax:310-317-4488
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-20
Last Update Date:2017-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17658225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty