MEDICARE: KATHLEEN KANG

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	235Z00000X	Speech-Language Pathologist	SP 19989	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A3152471	OTHER	CA	DRIVER LICENSE #

General Provider Information

NPI Number	:	1629435805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN KANG

Provider Business Mailing Address
First Line	:	5601 W OLYMPIC BLVD
Second Line	:	UNIT 101
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-4855
Country	:	US
Telephone Number	:	310-748-1146
Fax Number	:

Provider Business Practice Location Address
First Line	:	5601 W OLYMPIC BLVD
Second Line	:	101
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-4855
Country	:	US
Telephone Number	:	310-748-1146
Fax Number	:

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

Provider Enumeration Date	:	01/19/2016
Last Update Date	:	01/19/2016

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Directions to “ KATHLEEN KANG ” Practice Location

Language	Start Address	Practice Location

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