MEDICARE: KIM CORRICK OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	993	CA

General Provider Information

NPI Number	:	1295021459
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM CORRICK OT

Provider Business Mailing Address
First Line	:	300 WISCONSIN AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90814-6749
Country	:	US
Telephone Number	:	562-336-8823
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 WISCONSIN AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90814-6749
Country	:	US
Telephone Number	:	562-336-8823
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2011
Last Update Date	:	06/24/2011

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