Healthcare Provider Details

I. General information

NPI: 1013477223
Provider Name (Legal Business Name): IRENE SHIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21515 HAWTHORNE BLVD STE G100
TORRANCE CA
90503-6501
US

IV. Provider business mailing address

6160 CORNERSTONE CT E STE 100
SAN DIEGO CA
92121-3724
US

V. Phone/Fax

Practice location:
  • Phone: 424-571-2618
  • Fax: 424-571-2339
Mailing address:
  • Phone: 858-216-8837
  • Fax: 619-941-0276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number24407
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: