Healthcare Provider Details

I. General information

NPI: 1427262344
Provider Name (Legal Business Name): KIMBERLEE ERICKSON DAUGHERTY OTRL, CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST
LOS ANGELES CA
90033-1029
US

IV. Provider business mailing address

212 6TH ST
SEAL BEACH CA
90740-6133
US

V. Phone/Fax

Practice location:
  • Phone: 323-226-5096
  • Fax:
Mailing address:
  • Phone: 323-226-5096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3578
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: