Healthcare Provider Details

I. General information

NPI: 1710815808
Provider Name (Legal Business Name): JOANN KIM OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 NORTHERN BLVD STE 19
GREAT NECK NY
11021-4802
US

IV. Provider business mailing address

170 FAIRHAVEN DR APT B15
JERICHO NY
11753-2461
US

V. Phone/Fax

Practice location:
  • Phone: 516-829-0030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number031045
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: