MEDICARE: KIMIKO ALEXANDRA HENNESSY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	22089	CA

General Provider Information

NPI Number	:	1235709973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMIKO ALEXANDRA HENNESSY

Provider Business Mailing Address
First Line	:	6160 CORNERSTONE CT E
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3720
Country	:	US
Telephone Number	:	858-673-5437
Fax Number	:

Provider Business Practice Location Address
First Line	:	6160 CORNERSTONE CT E
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3720
Country	:	US
Telephone Number	:	858-304-6440
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2021
Last Update Date	:	02/13/2025

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