Healthcare Provider Details

I. General information

NPI: 1902198575
Provider Name (Legal Business Name): KYUNG-RAN TAE OT/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2011
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 HILLTOP DR APT 31
REDDING CA
96003-3238
US

IV. Provider business mailing address

275 HILLTOP DR APT 31
REDDING CA
96003-3238
US

V. Phone/Fax

Practice location:
  • Phone: 714-714-5597
  • Fax:
Mailing address:
  • Phone: 714-714-5597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT10347
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: