Provider Demographics
NPI:1760831853
Name:BAE, EUN KYUNG
Entity type:Individual
Prefix:
First Name:EUN KYUNG
Middle Name:
Last Name:BAE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 CRENSHAW AVENUE
Mailing Address - Street 2:#301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019
Mailing Address - Country:US
Mailing Address - Phone:323-939-0840
Mailing Address - Fax:323-949-0850
Practice Address - Street 1:903 CRENSHAW BLVD
Practice Address - Street 2:#301
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-1964
Practice Address - Country:US
Practice Address - Phone:323-939-0840
Practice Address - Fax:323-939-0850
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT16277225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOT16277OtherCALIFORNIA OCCUPATIONAL THERAPY BOARD
OT16277OtherOCCUPATIONAL THERAPIST