Provider Demographics
NPI:1811653983
Name:PENG, BRIAN TIM (OTR/L)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:TIM
Last Name:PENG
Suffix:
Gender:M
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 1:109 CAMPANITA CT
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-2330
Mailing Address - Country:US
Mailing Address - Phone:626-688-1254
Mailing Address - Fax:
Practice Address - Street 1:109 CAMPANITA CT
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-2330
Practice Address - Country:US
Practice Address - Phone:626-688-1254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20685225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist