Healthcare Provider Details

I. General information

NPI: 1922402965
Provider Name (Legal Business Name): KIMBERLY GARDENER OTD, OTR/L, SWC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIMBERLY KORETOFF OTD, OTR/L

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1932 14TH ST
SANTA MONICA CA
90404-4605
US

IV. Provider business mailing address

1932 14TH ST
SANTA MONICA CA
90404-4605
US

V. Phone/Fax

Practice location:
  • Phone: 949-683-0884
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number12467
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: