Healthcare Provider Details

I. General information

NPI: 1215849989
Provider Name (Legal Business Name): LYDIA KIM-DELA FUENTE OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15110 PARAMOUNT BLVD
PARAMOUNT CA
90723-4337
US

IV. Provider business mailing address

11211 CANDOR ST
CERRITOS CA
90703-6521
US

V. Phone/Fax

Practice location:
  • Phone: 951-588-9661
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number28669
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: