Provider Demographics
NPI:1316171614
Name:BAE, SOYOUNG (OTD, OTR/L)
Entity type:Individual
Prefix:DR
First Name:SOYOUNG
Middle Name:
Last Name:BAE
Suffix:
Gender:
Credentials:OTD, OTR/L
Other - Prefix:DR
Other - First Name:SOYOUNG
Other - Middle Name:ESTHER
Other - Last Name:AHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13522 FELSON ST
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-8913
Mailing Address - Country:US
Mailing Address - Phone:213-500-0829
Mailing Address - Fax:
Practice Address - Street 1:13522 FELSON ST
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-8913
Practice Address - Country:US
Practice Address - Phone:213-500-0829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-14
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11604225XM0800X, 225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics