Healthcare Provider Details

I. General information

NPI: 1881194207
Provider Name (Legal Business Name): KRISTIN M WONG OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4617 W 136TH ST
HAWTHORNE CA
90250-5735
US

IV. Provider business mailing address

233 ORANGEFAIR MALL
FULLERTON CA
92832-3038
US

V. Phone/Fax

Practice location:
  • Phone: 714-870-6116
  • Fax:
Mailing address:
  • Phone: 714-870-6116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number22066
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: