Healthcare Provider Details

I. General information

NPI: 1790613354
Provider Name (Legal Business Name): GRACE SUE YI OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2985 BEAR ST
COSTA MESA CA
92626-4300
US

IV. Provider business mailing address

2985 BEAR ST
COSTA MESA CA
92626-4300
US

V. Phone/Fax

Practice location:
  • Phone: 714-424-5000
  • Fax:
Mailing address:
  • Phone: 714-424-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number8871
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: