=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902198575
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYUNG-RAN TAE OT/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2011
-----------------------------------------------------
Last Update Date | 04/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9764 GARDEN GROVE BLVD
-----------------------------------------------------
City | GARDEN GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92844-1615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-534-0007
-----------------------------------------------------
Fax | 714-534-0004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1324 S CITRUS AVE APT 6
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92833-4748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-714-5597
-----------------------------------------------------
Fax | 714-534-0004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT10347
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------