Provider Demographics
NPI:1366919672
Name:KIM, SUSAN BOKSUK (COTA/L)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:BOKSUK
Last Name:KIM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6404 FAIRBANKS LN
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-7615
Mailing Address - Country:US
Mailing Address - Phone:301-471-8809
Mailing Address - Fax:
Practice Address - Street 1:5215 W CEDAR LN
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-1548
Practice Address - Country:US
Practice Address - Phone:301-897-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02693224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant